Consent for Treatment, Payments and Healthcare Operations

Please correct the errors described below.

I consent to the use or disclosure of my child’s protected health information by Southwest Children’s Clinic, LLC for the purposes of diagnosing or providing treatment to my child, obtaining payment for my child’s health care bills or to conduct health care operations of Southwest Children’s Clinic, LLC. I understand that diagnosis or treatment of my child by Pari L. Mashkuri M.D., Valerie L. Rahaniotis M.D, Jeffrey B. Jackson M.D, L. Harper Randall M.D., Molly Montes M.D., or covering physicians, may be conditioned upon my request as evidenced by my signature on this document.

I understand I have the right to request a restriction as to how my child’s protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Southwest Children’s Clinic, LLC is not required to agree to the restrictions that I may request. However, if Southwest Children’s Clinic, LLC agrees to a restriction that I request, the restriction is binding on Southwest Children’s Clinic, LLC and Pari L. Mashkuri M.D., Valerie L. Rahaniotis M.D, Jeffrey B. Jackson M.D, Molly Montes M.D., L. Harper Randall M.D.

I have the right to revoke this consent, in writing, at any time, except to the extent that Pari L. Mashkuri M.D., Valerie L. Rahaniotis M.D, Jeffrey B. Jackson M.D, L. Harper Randall M.D., Molly Montes M.D., or Southwest Children’s Clinic, LLC has taken reliance on this consent.

My child’s “protected health information” means health information, including our demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my child’s past, present or future physical or mental health condition and identifies me and my child, or there is a reasonable basis to believe the information may identify my child and me.

I understand I have a right to review Southwest Children’s Clinic, LLC’s Notice of Privacy Practices prior to signing this document. The Southwest Children’s Clinic, LLC’s Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my child’s treatment, payment of my bills or in the performance of health care operations of the Southwest Children’s Clinic, LLC. The Notice of Privacy Practices for Southwest Children’s Clinic, LLC is also provided on the wall in the patient waiting room. This Notice of Privacy Practices also describes my child’s rights and the Southwest Children’s Clinic, LLC’s duties with respect to my child’s protected health information.

I understand that if my child’s physician or any person employed by or under the direction and control of my child’s physician(s), is directly exposed to my child’s body fluids in any manner which may, according to the current guidelines of the Center for Disease Control, transmit the human immunodeficiency virus (HIV) or hepatitis B or C viruses, that I am deemed by law to have consented to testing for infection with HIV or hepatitis B or C viruses. I further understand that by law I will have deemed to have consented to the release of these test results to the person who is exposed to my child’s body fluids.

Southwest Children’s Clinic, LLC reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail, or by asking for one at the time of my child’s next appointment.

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

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