Patient Consent for Use and Disclosure of Protected Health Information

STARLIGHT PEDIATRICS

Please correct the errors described below.

I hereby give my consent for STARLIGHT PEDIATRICS to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by STARLIGHT PEDIATRICS describes such uses and disclosures more completely.)

I have the right to review the Notice of Privacy Practices prior to signing this consent. STARLIGHT PEDIATRICS reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to: OFFICE MANAGER 500 HOLLY SPRINGS RD STE 101 HOLLY SPRINGS NC, 27540

With this consent, STARLIGHT PEDIATRICS may call my home or other alternative 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 my clinical care, including laboratory test results, among others. With this consent, STARLIGHT PEDIATRICS may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”

With this consent, STARLIGHT PEDIATRICS may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that STARLIGHT PEDIATRICS restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to allow STARLIGHT PEDIATRICS to use and disclose my PHI to carry out TPO.

In order to comply with HIPPA requirements and to maintain confidentiality of protected health information (PHI), only emails and text messages requesting follow up or non-urgent appointments will be attended. However, parents/guardians should not send PHI or patients’ pictures via email or text message to the physician. Starlight Pediatrics will attend your requests via phone and it is no able to reply emails and text messages that bridge HIPPA laws.

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, or later revoke it, STARLIGHT PEDIATRICS may decline to provide treatment to me.

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