Patient Registration Form Chart - Black Hills Ob-Gyn (Page 2 of 2) in pdf

PATIENT CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION

FOR TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS

1. I understand that as part of my health care, Black Hills Obstetrics and Gynecology originates, records,

and maintains health information about me describing my health history, symptoms, examination

and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that

this health information may be used or disclosed by Black Hills Obstetrics and Gynecology for treatment,

payment, and health care operations. For example, my health information serves as:

 A basis for planning my care and treatment;

 A means of communication among the many health professionals who contribute to my care;

 A source of information for applying my diagnosis and surgical information to my bill;

 A means by which a third-party payor can verify that services billed were actually provided; and

 A tool for routine health care operations, such as assessing quality and reviewing the competence

of health care professionals.

2. I acknowledge that I have been provided with Black Hills Obstetrics and Gynecology’s Notice of

Privacy Practices that provides a more complete description of information uses and disclosures. I

understand that I have the right to review the Notice of Privacy prior to signing this consent. I understand

that Black Hills Obstetrics and Gynecology reserves the right to change its Notice of Privacy Practices and

prior to implementation will mail a copy of any revised notice to the address I have provided.

3. I understand that I have the right to request restrictions as to how my health information may be used or

disclosed to carry out treatment, payment, or health care operations, and that Black Hills Obstetrics

and Gynecology is not required to agree to the restrictions requested but if it does, it is bound by such

restrictions.

4. I understand that I may revoke this consent in writing, except to the extent that Black Hills Obstetrics

and Gynecology has already taken action in reliance thereon. This signed consent shall remain in force

until the undersigned patient gives written notification, stating otherwise.

5. By signing this form, I consent to Black Hills Obstetrics and Gynecology’s use and disclosure of

my health information for treatment, payment, and health care operations.

6. I understand that this release of medical information may contain information regarding drug or

alcohol abuse, mental health issues and/or HIV (AIDS) and STD (Sexually Transmitted Diseases)

I do not have any restrictions to the use or disclosure of my health information.

I request the following restrictions to the use or disclosure of my health information:

______________________________________________________________________________

_____________ Staff Initials

Restrictions Accepted

Restrictions Denied

7. I, the undersigned, hereby assign to the physician(s) associated with Black Hills Obstetrics &

Gynecology LLP. all payments for medical services rendered to myself or my dependant.

Signature of Patient _________________________________________________Date______________

Signature of Guardian or Legal Representative __________________________Date______________

Witness____________________________________________________________Date_______________

Patient Registration Form Chart - Black Hills Ob-Gyn Page 2