Patient Privacy Agreement

Please correct the errors described below.

Patient Acknowledgement Of Receipt Of Notice Of Privacy PracticesAnd Consent/limited Authoization & Release Form

You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.

Date

The undersigned acknowledges that he/she has reviewed the currently effective Notice of Privacy Practices for this facility. A copy of this signed, dated document shall be as effective as the original.

MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/FACILITIES IN THE FUTURE.

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.

Name of Patient

Signature for Patient / Guardian of Patient

Legal Representative / Guardian

Relationship to Legal Representative / Guardian

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:(This includes step-parents, grandparents, and any care takers who can have access to this patient's records)

Add Additional Name

I authorize contact from this facility to confirm my appointments, treatment, and billing information via:

Text/SMS to my cell phone

Call to cell phone

Call to home phone or another number

ANY/ALL

Please Provide New Number

I authorize information about my health to be conveyed via:

Text/SMS to my cell phone

Call to cell phone

Call to home phone or another number

ANY/ALL

Please Provide New Number

Your information will be encrypted.

Electronic signature

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I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

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