New Patient Medical Information (Page 2 of 3) in pdf

Page 2 of 3

PATIENT CONSENT FOR USE AND

DISCLOSURE OF PROTECTED HEALTH

INFORMATION (HIPAA)

Patient Name: __________________________________________________DOB: __________________

By my signature below, I hereby authorize Wiseman Family Practice (“Practice”) to disclose my protected health information

(PHI) so that the Practice may treat me, seek payment from third parties for such treatment, and generally carry on the Practice’s

treatment, payment and health care operations (TPO), (e.g., quality assurance). I also authorize the Practice to disclose my

medical information to insurers and providers outside of the Practice when necessary so that these providers may treat me, seek

payment for that treatment, and for the purpose of their health care operations.

With this consent, Wiseman Family Practice may call my home or other alternative location and leave a message on voice

mail or in person in reference to any items that assist the practice in carrying out treatment, such as appointment reminders,

insurance issues, and any calls pertaining to my clinical care, including laboratory results.

With this consent, Wiseman Family Practice may mail to my home or other alternative location, and/or e-mail any items that

assist the practice in carrying out TPO, such as test results, appointment reminders and patient financial statements.

With this consent, Wiseman Family Practice may speak with the following family members, friends, etc. whom you would

like to have access to your protected health information to assist the practice in carrying out TPO, such as discussing any

open or unpaid balance of my financial account, including visit reason, insurance-related matters, or any other medical

issues.

Name: _______________________________________________, Relationship

I have the right to request that Wiseman Family Practice restrict how it uses or discloses my PHI to carry out TPO. 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 allow Wiseman Family Practice to use and disclose my PHI to carry out TPO. 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, or later revoke it, Wiseman Family Practice may decline to provide treatment to me.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Wiseman Family Practice reserves

the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained through

our office.

I have reviewed this office’s Notice of Privacy Practices (HIPAA), which explains how my medical information can be used

and disclosed. I understand that I am entitled to receive a copy of this document.

Printed Patient Name: __________________________________________________________

Signature of Patient/Legal Guardian: ______________________________________Date: __________________

New Patient Medical Information Page 2