I, the undersigned, do hereby agree and give my consent for ADVANCED SURGICAL ASSOCIATES, LLC. to furnish medical care and treatment to (Name Stated Above) considered necessary and proper in diagnosing or treating his/her physical and mental condition.
The Department of Health and Human Services has established a "Privacy Rule" to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients' consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations .
As our patient we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment, or health care operations, in order to provide health care that is in your best interest.
We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent.
You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at Some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer.
You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice. You may review Advanced Surgical Associates, LLC's notice of privacy practices on their website or you can ask for a copy at the time of your office visit. The signing of the consent form verifies that you have received the ''Notice of Privacy Practices" information pamphlet as mandated by the Health Insurance Portability Act of 1996(HIPAA) and have been given the opportunity to review it.
CONSENT TO LEAVE A MESSAGE
Advanced Surgical Associates, LLC, in compliance with HIPAA guidelines, is very concerned with your privacy in relationship with your medical care. Please specify person (s) with whom we may discuss your personal health information. (Check all that apply):