Individual Consent

Please correct the errors described below.

Consent to the Use and Disclosure of Individually Identifiable Health Information for Treatment, Payment, and/or Health Operations

I understand that as a part of my health care, AKCRS, PC receives, originates, maintains, discloses, and uses individually identifiable health information, including, but not limited to, health records and other health information describing my health history, symptoms, examination and test results, diagnoses, treatment, treatment plans, and billing and health insurance information. I understand that AKCRS, PC and its physicians, other health care professionals, and staff may use this information to perform the following tasks: Diagnose my medical/psychiatric/psychological condition, plan my treatment and care, communicate with other health professionals concerning my care, document services for payment/reimbursement, conduct routine health care operations, such as quality assurance. I understand that my medical records may contain sensitive information including, but not limited to, the information listed below. I authorize this to be used, disclosed, received and /or exchanged for purposes of my treatment. Please disclose in the consent section if you object to use of one or more of the following types of information: HIV/AIDS, substance abuse, developmental disabilities, mental health, sexually transmitted diseases, and communicable diseases. A copy of the practice’s NOTICE OF PRIVACY PRACTICES has been available for my review that fully explains the uses and disclosures that this practice will make with respect to my individually identifiable health information. I understand that I have the right to review this NOTICE before signing this consent. AKCRS, PC has given me sufficient time to review this NOTICE and has answered any questions that I had to my satisfaction. I also understand that AKCRS, PC cannot use or disclose my individually identifiable health information other than as specified on the NOTICE. I also understand that AKCRS, PC reserves the right to change its notice and the practices detailed therein and will provide me with a copy of the revised notice by mail to the address that I have provided. I understand that I do not have to consent to the use or disclosure of my individually identifiable health information for treatment, payment, or health operations, but that if I do not consent, AKCRS, PC may refuse to provide me health care services unless applicable state or federal law requires AKCRS, PC to provide such services. I understand that I have the right to request restrictions on the use or disclosure of my individually identifiable health information to carry out treatment, payment, or health operations. I further understand that AKCRS, PC is not required to agree to the requested restriction but that, if it does agree, it must honor the restriction unless I request that I stop doing so or AKCRS, PC notifies me that it is no longer going to honor the request. I understand that I have the right to object to the use and/or disclosure of my individually identifiable health information to family members.

Please Initial Next to those Applicable:

We respect your right to privacy regarding your medical information. We will NOT share your information with any family member, friend, significant other, or spouse without your written consent. If you would like to authorize us to share your information with someone, please list them below. I consent to allowing the providers and staff of AKCRS, PC to discuss my PHI with my family members, significant other, or my personal representative

OR

I understand that I may revoke this consent in writing, but that revocation will not be affect to the extent that AKCRS, PC has already taken action in reliance on my earlier effective consent.

Updated 2/28/19

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