Date of Birth:
______ (Patient initials) Notice of Privacy Practices. I acknowledge that I have received the practice’s Notice of Privacy
Practices, which describes the ways in which the practice may use and disclose my healthcare information for its treatment,
payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the
Privacy Officer designated on the notice if I have a question or complaint.
I understand that this information may be disclosed
electronically by the Provider and/or the Provider’s business associates. To the extent permitted by law, I consent to the use
and disclosure of my information for the purposes described in the practice’s Notice of Privacy Practices.
______ (Patient initials) Release of Information. I hereby permit practice and the physicians or other health professionals
involved in the inpatient or outpatient care to release healthcare information for purposes of treatment, payment, or healthcare
Healthcare information regarding a prior admission(s) at other HCA affiliated facilities may be made available to subsequent
HCA-affiliated admitting facilities to coordinate Patient care or for case management purposes. Healthcare information may
be released to any person or entity liable for payment on the Patient’s behalf in order to verify coverage or payment
questions, or for any other purpose related to benefit payment. Healthcare information may also be released to my
employer’s designee when the services delivered are related to a claim under worker’s compensation.
If I am covered by Medicare or Medicaid, I authorize the release of healthcare information to the Social Security
Administration or its intermediaries or carriers for payment of a Medicare claim or to the appropriate state agency for
payment of a Medicaid claim. This information may include, without limitation, history and physical, emergency records,
laboratory reports, operative reports, physician progress notes, nurse’s notes, consultations, psychological and/or
psychiatric reports, drug and alcohol treatment and discharge summary.
Federal and state laws may permit this facility to participate in organizations with other healthcare providers, insurers, and/or
other health care industry participants and their subcontractors in order for these individuals and entities to share my health
information with one another to accomplish goals that may include but not be limited to: improving the accuracy and
increasing the availability of my health records; decreasing the time needed to access my information; aggregating and
comparing my information for quality improvement purposes; and such other purposes as may be permitted by law. I
understand that this facility may be a member of one or more such organizations. This consent specifically includes
information concerning psychological conditions, psychiatric conditions, intellectual disability conditions, genetic information,
chemical dependency conditions and/or infectious diseases including, but not limited to, blood borne diseases, such as HIV
Disclosures to Friends and/or Family Members
DO YOU WANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM THE PROVIDER MAY
DISCUSS YOUR MEDICAL CONDITION? IF YES, WHOM?”
I give permission for my Protected Health Information to be disclosed for purposes of communicating results, findings and care
decisions to the family members and others listed below:
Patient may revoke or modify this specific authorization and that revocation or modification must be in writing.
Updated: June 12, 2015, replacing November 21, 2013 version