HIPAA Form & Consent to Technology Communications

Protected Health information may be disclosed to insurance companies, managed care organizations or referring physicians in the course of treatment, payment of healthcare operations. When information is disclosed to another entity, it may be subject to redisclosure by the recipient and may no longer be protected by the HIPAA Privacy Rule. You have the right to refuse or restrict our disclosure of your information. However, if you refuse or restrict disclosure, we will be unable to provide treatment to you. If you wish to refuse or restrict disclosure, please ask for a HIPAA Restriction form.

You have the right to determine how we may communicate with you concerning your treatment or payment for services. Please indicate below where we may leave messages for you.

I consent that Dawn L. Shogren M.D, P.A. may contact me by:

Please check all that apply:

Your health care is important to us. In order to provide you with the best possible care, we occasionally send text messages or emails to our patients about their health care and/or appointments.

I consent that Dawn L. Shogren, M.D., P.A. may discuss or disclose information regarding my clinical care and/or financial history with those listed here:

This consent will expire one year from the date of signature.

I acknowledge that I have been given an opportunity to read and understand Dawn L. Shogren, M.D., P.A.’s Notice of Privacy Practices.

By submitting this form, I indicate that I am the person legally responsible for all use of technology, that I am at least 18 years of age, and that I agree to all terms and conditions of use for phone, email, and text messaging.

You may revoke this consent in writing except to the extent that the practice has already made disclosures in reliance upon your prior consent. If you do not sign this consent, Dawn L. Shogren, M.D., P.A. may decline to provide you treatment.