Authorization of use and Disclosure of Protected Health Information

Authorization of Use and Disclosure of Protected Health Information

Appointment Reminders: The practice may use your information to remind you about upcoming appointments. Typically, appointment reminders are sent by Email or regular mail, or a brief, non-specific message may be left on voicemail of the phone number you provided. If you don’t approve of these methods and would like alternative reminder methods (i.e., email) please indicate those methods in the space provided (samples of appointment reminders are available upon request):

How would you like to be contacted regarding appointments, treatment and /or other information pertinent to your healthcare and/or payment for your healthcare provided at Serenity Gyn & Functional Medicine (Check all that apply)

Regular Mail

Home Telephone

Work Telephone

Cell Phone

Other

If other, Please Specify:

If you have an answering machine or voice mail, may we leave messages regarding appointments, treatment and/or other pertinent information regarding your healthcare and/or payment for your healthcare provided at this office

Yes No N / A

If “NO”, how else may we contact you regarding this information?

Please list any other restrictions regarding messages or reminders regarding your healthcare:

Other Uses and Disclosures: Disclosure of your health information or its use for any purpose other than those listed in the “Notice of Privacy Policies and Practices” brochures and/or consent requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision. You have the right to request restrictions on use and disclosure of your health information.

I would like the following restrictions regarding the use and disclosure of my health information:

Serenity GYN & Functional medicine
220 N Park Blvd
Grapevine, Texas 76051
(817) 280-9616

Authorization of Use and Disclosure of Protected Health Information

Persons Authorized to Receive Information:
Health information Miriam Torres, M.D. collects or receives about you may be disclosed to the following persons:

Name

Relation

Organization

Name

Relation

Organization

Use and Disclosure of Information:

Name:

I authorize the person(s) listed above to receive all health information about appointments, treatment and/or other information pertinent to my healthcare and/or payment for my healthcare provided at Serenity GYN & Functional Medicine.

I do not authorize the following information to be disclosed to any other parties except to me as the patient.

If not, Please specify

Right to Terminate or Revoke Authorization: You may revoke or terminate this authorization by submitting a written revocation of Miriam Torres, M.D. You should contact the PRIVACY OFFICIAL or other authorized representative to terminate this authorization.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Your information will be encrypted.