Consent for Treatment and Use and Disclosure of Protected Health Information

White Coat House Calls, PLLC may mail to my residence/home or other designated location any items that assist the practice in carrying out treatment, payment, or healthcare operations.

I have the right to request that White Coat House Calls, PLLC restrict how it uses or discloses my PHI to carry out treatment, payment or healthcare operations regarding myself. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. I authorize payment of insurance benefits directly to White Coat House Calls, PLLC. I understand that I am fully responsibly for any medical charge incurred in the course of my treatment that is considered copay, deductible, or other type of unpaid service/services in excess of any hospitalization or health insurance that might be applicable. I hereby authorize my provider/physician to release pertinent information to my health insurance company/companies required in the course of my examination, treatment or prior authorization needed for treatment. I understand that 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, White Coat House Calls, PLLC has the right to decline to provide treatment to you.

By signing this form, I am consenting to White Coat House Calls, PLLC use and disclosure of my personal health information to carry out treatment, payment and healthcare operations.

HIPPA Consent

The Health Insurance Portability and Accountability Act of 1996 (HIPAA), established a Privacy Rule to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.

As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate or necessary, we provide the minimum necessary information only to those we feel are in need of your health care information regarding treatment, payment or health care operations, in order to provide health care that is in your best interest.

We fully support your access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with the physician and not patients), and may have to disclose personal health information for purposes of treatment, payment or health care operations. These entities are most often not required to obtain patient consent.

You may refuse to consent to the use or disclosure of your personal health information, but this must be done in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information. If you choose to give consent in this document, at some future time you may request to refuse all or part of your Personal Health Information. You may not revoke actions that have already been taken which relied on this or a previously signed consent.

Telehealth Consent

Telehealth involves the use of electronic communications between a patient and a provider/staff member for the purpose of improving patient care. The information obtained during a telehealth visit may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records
• Medical images
• Labs
• Live two-way audio and/or video

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification, conversations and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

There are potential risks associated with the use of telehealth communications. These risks include, but may not be limited to:

• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment or service area of the patient or provider at time of telehealth encounter;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors; Please initial after reading this page:

By signing this form, I understand the following:

1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth, and that no information obtained in the use of telehealth which identifies me will be disclosed to researchers or other entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand that I have the right to inspect all information obtained and recorded in the course of a telehealth interaction, and may receive copies of this information.
4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My provider has explained the alternatives to my satisfaction.
5. I understand that telehealth may involve electronic communication of my personal medical information.
6. I understand that it is my duty to inform my providers of electronic interactions regarding my care that I may have with other healthcare providers.
7. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

Patient Consent For The Use of Telehealth

I have read and understand the information provided above regarding telehealth, have discussed it with my provider or certain staff members, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth in my medical care.

I hereby authorize _Morresa Bain FNP_ to use telehealth in the course of my diagnosis and treatment.

Authorization to Release Medical Records

hereby authorize and request to release healthcare records/information of the above named patient to Morresa Bain FNP at the above address/fax number.

We kindly ask you assist to expedite this record request within 10 business days and fax to 903-765-7723, in order to ensure timely continued evaluation and treatment.

This request and authorization applies to:

This authorization expires with termination of White Coat House Calls, PLLC services.

You make revoke this consent at anytime in writing to White Coat House Calls, PLLC address listed above.