Add Additional Parent / Guardian
PRIMARY INSURANCE
SECONDARY INSURANCE
PREFERRED METHOD OF APPOINTMENT CONFIRMATION
Add Additional Condition
Add Additional Surgery
Add Additional Reason
Add Additional Medications
Add Additional Allergies
Add Additional Conditions
I understand that as part of the provision of healthcare services, Fairway Pediatrics, LLC creates and maintains health records and other information describing among other things, my health history, symptoms, examination and test results, diagnoses, treatment and any plans for further care or treatment.
I have been provided with a Notice of Privacy Practices that provides a more complete description of the uses and disclosures of certain health information. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their Notice and Practices and prior to implementation will mail a copy of any revised notice to the address I have provided. I understand that I have the right to object to use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operation (quality assessment and improvement activities, underwriting, premium rating, conducting or arranging for medical review, legal services, and auditing functions, etc.) and that the organization is not required to agree to the restrictions requested.
By signing this form, I consent to the use and disclosure of Protected Health Information about me for the purposes of treatment, payment and healthcare operations. I have the right to revoke this consent in writing, except where disclosures have already been made in reliance on my prior consent. This consent is given freely with understanding that:
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