PATIENT HIPAA ACKNOWLEDGEMENT AND CONSENT FORM
☞ Notice of Privacy Practices/Clinics
I acknowledge that I have received the practice/clinic’s Notice of Privacy Practice/clinics, which describes the ways in which the practice/clinic may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the Privacy Officer designated on the notice if I have a question or complaint. I understand that this information may be disclosed electronically by the Provider and/or the Provider’s business associates. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice/clinic’s Notice of Privacy Practice/Clinics.
☞ Communication About My Healthcare
I agree the Provider or an agent of the Provider or an independent physician’s office may contact me for the purposes of scheduling necessary follow-up visits recommended by the treating physician.
☞ Consent for Photographing or Other Recording for Security and/or Health Care Operations
I consent to photographs, digital or audio recordings, and/or images of me being recorded for patient care, security purposes and/or the practice’s/clinic’s healthcare operations purposes (e.g., quality improvement activities). I understand that the practice/clinic retains the ownership rights to the images and/or recordings. I will be allowed to request access to or copies of the images and/or recordings when technologically feasible unless otherwise prohibited by law. I understand that these images and/or recordings will be securely stored and protected. Images and/or recordings in which I am identified will not be released and/or used outside the facility without a specific written authorization from me or my legal representative unless otherwise permitted or required by law.
☞ Consent to Email, Cellular Telephone, or Text Usage for Appointment Reminders and Other Healthcare Communications
If at any time I provide an email address or cellphone number at which I may be contacted, I consent to receiving unsecure instructions and other healthcare communications at the email or text address I have provided or you or your EBO Servicer have obtained, at any text number forwarded, or transferred from that number. These instructions may include, but not be limited too: post-procedure instructions, follow-up instructions, educational information, and prescription information. Other healthcare communications may include, but are not limited to, communications to family or designated representatives regarding my treatment or condition, or reminder messages to me regarding appointments for medical care.
NOTE: You may opt out of these communications at any time. The practice/clinic does not charge for this service, but standard data, text messaging rates or cellular telephone minutes may apply as provided in your wireless plan (contact your carrier for pricing plans and details).
☞ Disclosures to Friends and/or Family
IF YOU WISH TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM THE PROVIDER OR STAFF MAY DISCUSS YOUR MEDICAL CONDITION(S), PROVIDE THE NAME, RELATIONSHIP TO PATIENT, AND CONTACT NUMBER IN YOUR RESPONSE.
I give permission for my Protected Health Information to be disclosed for purposes of communicating results, findings and care decisions to the family members and others listed in my response to this message (EXAMPLE: Jane Doe | Grandmother | 423-555-4321).
Patient/Representative may revoke or modify this specific authorization and that revocation or modification must be in writing.