Consent for the Use and Disclosure of Protected Health Information

By signing below, you consent to the use and disclosure of your protected health information by Highland Pediatrics & Adolescent Medicine, SC. (HPAAM), our staff, and our business associates for treatment, payment and health care operations (TPO).

HPAAM is also enrolled in the Illinois I-Care Immunization Registry program. Immunization as well as demographic information is uploaded to the state registry. Patients automatically consent to release of this information, unless you Opt Out. To Opt Out, you must sign an Opt Out of Registry Form which is available at the receptionist desk.

You further consent for HPAAM to call or mail to your home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to your clinical care, including laboratory results among others.

Provided, is a copy of our Notice of Privacy Practices which outlines the conditions under which we may use and disclose your Protected Health Information. The terms of this Notice may change from time to time as requirements of the law are defined, clarified, or changed. If the terms do change, you may obtain a revised Notice by simply contacting this office at 618-654-4449 and requesting a revised Notice. We will also post any revisions to the Notice in the facility and on the Highland Pediatrics Web site.

You have the right to request that we restrict our uses or disclosures of your protected health information, which we are otherwise permitted to make for treatment, payment and heath care operations, although we are not required to agree to these restrictions. However, if we agree to further restrictions, they are binding on us.

Finally, you have the right to revoke the consent in writing, except to the extent that we have taken action in reliance on it.