Notice of Privacy Practices Waiver

Patient Consent for Use and Disclosure of Protected Health Information

I hereby give my consent for Margolin, Keinarth & Alberda, M.D. to use and disclose my protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). The notice of Privacy Practices provided by Margolin, Keinarth & Alberda, M.D. describes such uses and disclosures more completely.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Margolin, Keinarth & Alberda, M.D. reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to:

Billing Supervisor, 5222 Burnet Rd, Ste 200, Austin, TX 78756.

With this consent Margolin, Keinarth & Alberda, M.D. may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any calls pertaining to my clinical care, including laboratory results.

With this consent, Margolin, Keinarth & Alberda, M.D. may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminders and patient financial statements. Please check your preferred contact method:

(i.e.: spouse’s name) to assist the practice in carrying out TPO, such as discussing any open or unpaid balance of my financial account, including visit reason, and insurance related matters. Unless otherwise stated at time of service by signing the Restriction of Use and Disclosure of Protected Health Information form denying access to the specific reason stated on form.

I have the right to request that Margolin, Keinarth & Alberda, M.D. restrict how it uses or discloses my PHI to carry out TPO. 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 allow Margolin, Keinarth & Alberda, M.D. to use and disclose my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Margolin, Keinarth & Alberda, M.D. may decline to provide treatment to me.

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.