Suburban Geriatrics Acknowledgement Form Of Receipt Of Notice Of Privacy Practices (Page 2 of 2) in pdf

SUBURBAN GERIATRICS

CONSENT FOR USE/ DISCLOSURE OF HEALTH INFORMATION

Patient’s Name:

Patient’s Date of Birth:

Patient’s SSN:

Notice to Patient:

By signing this form, you grant us consent to use and disclose your protected health care

information for the purposes of treatment, various activities associated with payment and

health care operations. Our Notice of Privacy Practices provides more details on our

treatment, payment activities and health care operations. If there is not a copy of the Notice

accompanying this Consent for, please ask for one. We encourage you to read it since it

provides details on how information about you may be used and/or disclosed and describes

certain rights you have regarding your health care information.

As stated in our Notice of Privacy Practices, we reserve the right to change our privacy

practices. If we should do so, we will issue a revised notice. Since revisions may apply to

your health care information, you have the right to receive a cop by contacting our Privacy

Officer.

You have the right to revoke consent by giving written notice to our privacy officer. The

revocation will not affect actions that were already taken in reliance upon this consent. You

should also understand that if you revoke this consent we may decline to treat you.

You are entitled to a copy of this Consent Form after you have signed it.

(To Be Completed by Patient or Patient’s Representative)

I, ___________________________________________, have read the contents of this Consent

Form and the Notice of Privacy Practices. I understand that I am giving you consent to use and

disclose my health care information to carry out treatment, payment activities and health care

operations.

_________________________________________________________

_____________

Patient’s Signature or Signature of Patient’s Representative

Date

_______________________________________________

_______________________

Printed Name of Patient’s Representative

Relationship to Patient

Privacy Officer: Colleen Moran RN, Office Manager

Practice Address: 190 W. Germantown Pike, Suite 100, East Norriton PA, 19401

Phone: 610-272-8221

Fax: 610-272-5655

Email:

HIPAA Consent for Use/Disclosure of Health Information

This form does not constitute legal advice and covers only federal, not state law.

Suburban Geriatrics Acknowledgement Form Of Receipt Of Notice Of Privacy Practices Page 2