In order to comply with the HIPAA regulations outlined in our NOTICE OF PRIVACY PRACTICES, Delaware Foot and Ankle Group will not disclose your medical information without your written permission except as needed for your medical TREATMENT, or in order to obtain PAYMENT from an insurance company for medical services rendered or to facilitate the initial healthcare OPERATIONS of Delaware Foot and Ankle Group.
By signing below, you will be authorizing Delaware Foot and Ankle Group to use your protected health information(PHI) so that a practitioner will be able to record information in your medical record in order to diagnose your condition and determine the best course of treatment for you. In addition, Delaware Foot and Ankle Group will be able to provide your medical information to other health care providers involved in your care.
Also, Delaware Foot and Ankle Group will use your protected health information to obtain payment from your insurance company. This information will include your diagnosis and a listing of the medical services you received.
Lastly, Delaware Foot and Ankle Group will continue to call your home or leave a message on an answering machine or in a voice mailbox regarding an appointment, test results, or other treatment issues, or billing and payment matters. If you are unwilling to sign this Consent for Use and Disclosure of Protected HealthInformation, Delaware Foot and Ankle Group may decline to provide treatment to you.
I have read and I understand the information given above. I give my permission to have my protected health information used for my TREATMENT, PAYMENT, or other health-related OPERATIONS of Delaware Foot and Ankle Group.
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.