With my consent, Gardens Dermatology may use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operations (TPO). Please refer to Gardens Dermatology’s Notice of Privacy Practice for a more complete description of such uses and disclosures.
I have the right to review the Notice of Privacy Practices prior to signing this consent. Gardens Dermatology reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practice may be obtained by forwarding a written request to the Gardens Dermatology Privacy Office at 11030 RCA Center Drive, Suite 3015, Palm Beach Gardens, FL 33410.
With my consent, Gardens Dermatology may call my home or other designated location and leave a message on my voicemail, or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any issue pertaining to my clinical care, including laboratory results or medications, etc.
With my consent, Gardens Dermatology may send mail to my home or other designated location. These items include but are not limited to carrying out TPO: for example, appointment reminder cards and patient statements.
I have the right to request that Gardens Dermatology restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restriction, but if it does, it is bound by this agreement.
By signing this form, I am consenting to Gardens Dermatology’s use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Gardens Dermatology may decline to provide treatment to me.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.