New Patient Forms - Central Illinois Dermatology (Page 3 of 3) in pdf

PATIENT CONSENT FOR USE AND DISCLOSURE OF

PROTECTED HEALTH INFORMATION (PHI)

With my consent, Central Illinois Dermatology, S.C. may use and disclose protected

health information (PHI) about me to carry out treatment, payment and health care

operations (TPO).

Please refer to Central Illinois Dermatology’s Notice of Privacy Practices for a more

complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. I

understand the Notice I received explains my rights and contains information to assist

me if I should have questions or a complaint. Central Illinois Dermatology, S.C. reserves

the right to revise its’ Notice of Privacy Practices at any time. A revised Notice of

Privacy Practices may be obtained by forwarding a written request to Central Illinois

Dermatology’s privacy officer at 5401 N. Knoxville, Ste. #115, Peoria, IL 61614.

With my consent, Central Illinois Dermatology may call numbers listed on my patient

information sheet for home, work, cellular phone or other designated location and leave

a message on voice mail or in person in reference to any items that assist the practice

in carrying out TPO, such as appointment reminders, insurance items, and any call

pertaining to my clinical care, including laboratory results. By signing below, I agree to

any fees or charges that I may incur for incoming calls, and/or outgoing calls to or from

any such number given, without reimbursement from Central Illinois Dermatology.

With my consent, Central Illinois Dermatology may mail to my home or other designated

location any items that assist the practice in carrying out TPO, such as appointment

reminder notes and patient statements.

The practice is not required to agree to my requested restrictions, but if it does, it is

bound by this agreement. By signing this form, I am consenting to Central Illinois

Dermatology’s use and disclosure of my PHI to carry out TPO.

By signing this form I, or the person signing for me, acknowledge receiving a ‘Notice of

Privacy Practices’ from Central Illinois Dermatology. I may revoke my consent in writing

except to the extent that the practice has already made disclosures in reliance upon my

prior consent. If I do not sign this consent, Central Illinois Dermatology may decline to

provide treatment to me.

_______________________________

____________________________

Patients’ Name (Printed Please)

Signature of Patient or Legal Guardian

____________________

Date

112 (5/13) CMFI

New Patient Forms - Central Illinois Dermatology Page 3