Patient Signature Authorization & Confidentiality Form (Page 2 of 2) in pdf

Contact Instructions

YES

______I authorize the physicians and staff of MUC to leave information at the designated phone number

and/or email address (below) regarding my care including, (but not limited to), scheduled appointments, lab

and x-ray results. Results may be given to the individuals answering the phone or left on the message

machine.

______I do not authorize the physicians and staff of MUC to leave information regarding my health care or

scheduled appointments on a message machine or given to any person except myself.

I authorize the physicians and staff of MUC to communicate any and all aspects of my medical care, including but not

limited to financial information with:

Name: _______________________________

Relationship: __________________

Name: _______________________________

Relationship: __________________

I can be contacted at the following phone number: ___________________________________.

Email address: ____________________________________

The right-to-privacy pledges tell consumers how their private medical information will be used for treatment, billing and

business operations. It also spells out what information our office can disclose about our patients. Thank you.

Patient Consent Form

The department of Health and Human services has 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 and necessary, we provide the minimum necessary information to only those we feel are in need of your

health care information and information about treatment, payment or health care operations, in order to provide health

care that is in your best interest.

We also want you to know that we support your full access to your personal medical records. We may have indirect

treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may

have to disclose personal health information for purpose 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 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 (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or

part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed

consent.

If you have any objections to this form, please ask to speak with our HIPAA compliance officer.

You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have

reviewed our privacy notice. Signature below is only acknowledgement that you have received this notice of our

privacy practices:

Signature________________________________________________________________Date___________________

Patient Signature Authorization & Confidentiality Form Page 2