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PATIENT NAME: ____________________________________

D. O. B. _______________________

Patient Consent for the Use/ Disclosure of Protected Health Information

I understand my/ the patient’s health information is private and confidential. I understand the Northern Arizona Allergy

works hard to protect my / the patient’s privacy and preserve the confidentiality of my/ the patient’s health information.

I understand that Northern Arizona Allergy may use and disclose my/ the patient’s health information to provide

treatment to me/ the patient, to handle billing and payment, and to take care of other healthcare operations. In general,

there will be no other uses and disclosure of information unless I permit it. I understand that sometimes the law may

require the release of this information without my permission. These situations are very unusual. (One example would

be if you/ the patient threatened to hurt someone.)

Northern Arizona Allergy has a detailed document labelled the “Notice of Privacy Practices”. It contains the detailed

instructions and protocols regarding the use and disclosure of health information. I understand I have the legal right to

read the “Notice of Privacy Practices” before I sign this consent.

Northern Arizona Allergy may update this form accordingly. If I ask, Northern Arizona Allergy will provide me with the

most current “Notice of Privacy Practices” form.

Under the terms of this consent, I can ask Northern Arizona Allergy to restrict how my/ the patient’s health information

is used or disclosed. I understand that Northern Arizona Allergy does not have to agree to my/ the patient’s request. If

Northern Arizona Allergy does agree to my/ the patient’s request, I understand that Northern Arizona Allergy will agree

to follow these limits.

I may cancel this consent in writing at any time by doing the following:

1. You/ the patient must provide a letter that has been signed and dated appropriately to Northern Arizona

Allergy. If I write a letter, it must say that “I want to revoke my/ the patient’s consent to authorize the use and

disclosure of my/ the patient’s health information for treatment, payment, and healthcare operations.”

If I revoke this consent, Northern Arizona Allergy does not have to provide any further healthcare services to me/ the

patient.

My signature below indicates that I have read and have been given the chance to review a current copy of Northern

Arizona Allergy’s “Notice of Privacy Practices.” My signature means that I agree to allow Northern Arizona Allergy to use

and disclose my/ the patient’s protected health information to carry out treatment, payment, and healthcare

operations.

____________________________________________________

_____________________________

Patient or legally authorized individual signature

Date

___________________________________________________

_____________________________

Patient name (please print)

Relationship to patient

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