Patient Consent/ HIPAA

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Consent for use/disclosure of health information

Notice to patient:

You grant Women’s Healthcare Associates P.A. DBA Rosemark WomenCare Specialists to use and disclose your protected health care information for the purposes of treatment, various activities associated with payment and health care operations. Our Notice of Privacy Practices provides more details on our treatment, payment activities and health care operations. If there is not a copy of the Notice accompanying this Consent form, please ask for one. We encourage you to read it since it provides details on how information about you may be used and/or disclosed and describes certain rights you have regarding your health care information.

As stated in our Notice of Privacy Practices, we reserve the right to change our privacy practices. If we should do so, we will issue a revised Notice. Since revisions may apply to your health care information, you have a right to receive a copy by contacting our Privacy Officer.

You have the right to revoke your Consent by giving written notice to our Privacy Officer. The revocation will not affect actions that were already taken in reliance upon this Consent. You should also understand that if you revoke this Consent, we may decline to treat you. You are entitled to a copy of this Consent Form after you have signed it.

HIPAA notice of privacy practice

I have been given a copy of the HIPPA Notice of Privacy Practices. I have read the contents of the above consent form and Notice of Privacy Practices. I understand that I am giving you my consent to use and disclose my health care information to carry out treatment, payment, activities and health care operations.

Your typed full name will act as your digital signature

To view the "Rosemark Privacy policy" please click here: Privacy Policy

Release of information authorization

Personal health information CANNOT be released to anyone including your spouse/guardian without your consent. If you wish to authorize the release of your information please provide the name & relationship of the individual below. Signature is valid for six years

Your typed full name will act as your digital signature

Your information will be encrypted.