I understand that Providers: Daryl M. McClendon, MD, Jeffrey W. Molloy, MD, Austin T. Nelson, MD, Martin P. Kaszubowski, MD, and/or Terri L. Tope, ANP (Referred to below as "The Providers") will use and disclose health information about me.
I understand that my health information may include information both created and received by the practice, maybe in the form of written or electronic records or spoken words, and may include information About my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information.
I understand and agree that The Providers’ may use and disclose my health information in order to:
- Make decisions about and plan for my care and treatment;
- Refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment.
- Determine my eligibility for a health plan or insurance coverage, and submit bills, claims, and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and
- Perform various offices, administrative, and business functions that support my physician's efforts to provide me with, arrange, and be reimbursed for quality, cost-effective health care.
I also understand that I have the right to receive and review a written description of how This Practice will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff, and other office personnel of The Providers’, and my rights regarding my health information.
I understand that the Notice of Privacy Practices may be revised from time to time and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy of the most current version of This Practice's Notice of Privacy Practices in effect will be posted in the waiting/reception area.
I understand that I have the right to ask that some and/or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and understand that "The Providers" is not required by law to agree to such requests.
Your Right to Privacy
We understand that you may have concerned relatives and we respect your right to privacy regarding medical information. Please list the names of individuals with whom we may share information without additional written consent.