Consent To Use & Disclose Health Information

This office is required by Federal Regulations to inform our Patients in regards to the use of your child’s health information in accordance to Health Insurance Portability & Accountability Act of 1996 or HIPAA.

PLEASE READ THE FOLLOWING CAREFULLY!

I understand that as part of my child’s health care, Young Pediatrics originates and maintains paper and/or electronic records describing my child’s health history, symptoms, examination and test results, diagnoses, treatments, and any plans for future care or treatment. I understand that this information serves as:

• A basis for planning care and treatment
• A means of communication among health professionals who contribute to my child’s care.
• A source of information for applying diagnosis and treatment information to my bill.
• A means by which a third-party can verify the services billed to me actually took place.

I understand and have been provided access to a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. This notice is located in the waiting area in plain view. I understand that I have the following rights and privileges:

• The right to review the Notice of Privacy Practices prior to signing this consent, allowing treatment, or making payment for services rendered.
• The right to object to the use of my child’s health information for directory purposes.

I understand that Young Pediatrics is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization may refuse to treat my child as permitted by Federal Regulations. I understand that Young Pediatrics reserve the right to change their Notice of Privacy Practices. I further understand that Young Pediatrics may use a computerized state vaccine registry to track immunization requirements and maintain immunization records. Young Pediatrics may enroll patients unless you inform us in writing that you do not wish to participate.

Please note that I consent to the following uses of my child’s medical information (Initial Below)

I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my child’s protected health information to another entity. I hereby consent to such disclosure for these permitted uses. I also hereby consent to such disclosures via fax.

I fully understand and accept the terms of this consent.

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.