Consent To Change Personal Health Information Preference (Page 2 of 3) in pdf

Consent To Change Personal Health Information Preference Page 2

A. Your Rights

At any time, you may decline to share your personal health information regarding care

you receive from other doctors or healthcare providers with Michael Mignoli, MD. Your

new preferences will take effect within 45 days of your request.

If you change your mind about declining to share personal health information, you can

complete this form and return it to the address listed in Section D, or you can call 1-800

MEDICARE (1-800-633-4227 (TTY: 1-877-486-2048)).

B. Your Information

Name (First and last name of the person with

Medicare):__________________________________

Physical Street

Address:____________________________________________________________

City:___________________________________________ State:_____ Zip

Code:____________

Mailing Address (if

different):_______________________________________________________

City:___________________________________________ State:_____ Zip

Code:____________

C. Change of Information Sharing Preference

Yes, please allow Medicare to share my personal health information with Michael

Mignoli, MD about care I received from other doctors or healthcare providers.

Signature: ________________________________________________________

Printed Full Name: _________________________________________________

Date: __________________

Check here if the person completing and signing this document is serving

in the capacity of a personal representative of the listed Medicare

Consent To Change Personal Health Information Preference Page 2