Consent for Use & Disclosure of Protected Health Information

and Receipt of Notice of Privacy Practices

Please correct the errors described below.

With my consent, Alabama Dermatology Associates, may use and disclose protected health information (PHI) about me to carry our treatment, payment and health care operation (TPO). Please refer to Alabama Dermatology Associate's Notice of Privacy Practices for a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. Alabama Dermatology Associates reserves the right to revise its Notice of Privacy Practices at Alabama Dermatology Associates anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Privacy Officer at 4410 Watermelon Road, Northport, AL 35473. With my consent, Alabama Dermatology Associates may call my home or other designated destination and leave a message on voicemail or in person in reference to any items that assist the practice in carrying our TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others. With my consent, Alabama Dermatology Associates my mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential. My medication records may be accessed electronically and added to my medical record. I have the right to request that Alabama Dermatology Associates restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to Alabama Dermatology Associatesuse and disclosure of my PHI to carry our TPO. I may revoke my consent in writing except that the practice has already made disclosures in reliance upon my prior consent. If i do not sign this consent, Alabama Dermatology Associates may decline to provide treatment to me.

We may communicate with you concerning your protected health information via email or texting. We also may leave detailed messages on your answering machine or voicemail. Please check the boxes below if you do not want us to use these communicaiton methods.

Please list the names of the people with whom we may communicate concerning your protected health information.

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

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