New Patient Packet - North Texas Perinatal Associates Page 2
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Acknowledgement of Receipt of Notice Privacy Practices
Authorization to Release Information to Others
“Committed to turning high-risk pregnancies into low-risk deliveries.”
Advance Directive / Living Will
Acknowledgement of Receipt of Notice of Privacy Practices
My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance
Portability & Accountability Act of 1996 (HIPAA). I understand that information can and will be used to:
•
Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly.
•
Obtain payment from third-party payers for my health care services
I have been informed of my provider’s Notice of Privacy Practices containing a more complete description of the uses of discl osures of my protected
health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my provider has
the right to change the Notice of Privacy Practices and that I may contact the office to obta in the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment of
healthcare operations, and I understand that you are not required to agree to my requested restriction, but if you do agree then you are bound to
abide by such restrictions.
I have read and acknowledged the above information. (Please initial.)________
Authorization to Release Information to Others
Many of our patients allow family members or others close to them to call and request information regarding their condition and/or treatment. Under
the requirements for HIPAA we are not allowed to give this information out without the patient’s consent. If you wish to have your condition and/or
treatment disclosed to someone else indicate below. You have the right to revoke this consent in writing, except where we have already made disclo-
sures in reliance on your prior consent.
No, you may not disclose my information to anyone but me. _______
Yes, you may disclose my information to the following people listed below. _______
Name:
Relationship to Patient:
Date:
Name:
Relationship to Patient:
Date:
Please provide phone numbers at which we can contact you or leave a message regarding lab results, appointment reminders,
changes to scheduled appointments and billing information.
Home Phone:
Work Phone:
Cell Phone:
Advance Directive / Living Will
Do you have an advance directive or living will? YES _____ NO _____
If no, are you interested in receiving information pertaining to one? YES _____ NO______
________________________________
__________________________________
Patient Name (Please print.)
Relationship to Patient (Please print.)
________________________________
__________________________________
Date of Signature
Signature of Patient or Guardian
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