Patient Consent for Use and Disclosure of Protected Health Information

I hereby give my consent for STARLIGHT PEDIATRICS to use and disclose protected health information (PHI) about my child/children to carry out Treatment, Payment and healthcare Operations (TPO). I have the right to review the Notice of Privacy Practices prior to signing this consent.

STARLIGHT PEDIATRICS Notice of Privacy Practices describes such uses and disclosures more completely. STARLIGHT PEDIATRICS reserves the right to revise its Notice of Privacy Practices at any time. A copy of the Notice of Privacy Practices can be obtained at the office or downloaded from the practice’s website.

With this consent, I authorize STARLIGHT PEDIATRICS to contact me in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, billing and clinical care, via phone calls, automated text, email and regular mail.

I have the right to request a restriction or limitation on the health information STARLIGHT PEDIATRICS uses or discloses for treatment, payment, or health care operations. STARLIGHT PEDIATRICS is not required to agree to my request for restrictions if it is not feasible to ensure compliance or if it will negatively affect the care provided to your child/children.

The restriction has to be requested in writing to the office. The request must include what information I want to limit and to whom I want the limits to apply.

In order to comply with HIPAA requirements and to maintain confidentiality of protected health information (PHI), parents/guardians should NOT send Protected Health Information or pictures via regular email, the practice website or text messages to the providers. Starlight Pediatrics is not able to reply non-secure emails and text messages that are non-HIPAA complaint. The secure method to exchange PHI information is via the patient portal or secure email.

I may revoke my consent for use and disclosure of PHI 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.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.