Hsu Huang Patient Registration
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1
2
3Consent
for
Purposes
of
Treatment,
Payment
and
Healthcare
Operations
I
consent
to
the
use
of
disclosure
of
my
protected
health
information
by
Dr.
Chung‐En
Huang
for
the
purpose
of
diagnosing
or
providing
treatment
to
me,
prescribing
medications
through
a
pharmacy
or
pharmaceutical
company,
obtaining
payment
for
my
health
care
bills
or
to
conduct
healthcare
operations
of
C.E.
Huang,
M.D.
I
understand
that
diagnosis
or
treatment
of
me
by
Dr.
Huang
may
be
conditioned
upon
my
consent
as
evidenced
by
my
signature
on
this
document.
I
understand
I
have
the
right
to
request
a
restriction
as
to
how
my
protected
health
information
is
used
or
disclosed
to
carry
out
treatment,
payment
or
healthcare
operations
of
the
practice.
Dr
Huang
is
not
required
to
agree
to
the
restrictions
that
I
may
request.
However,
if
C.E.
Huang
agrees
to
the
restrictions
that
I
request,
the
restriction
is
binding
on
C.E.
Huang.
I
have
the
right
to
revoke
this
consent,
in
writing,
at
any
time,
except
to
the
extent
that
C.
E.
Huang,
M.D.
has
taken
action
in
reliance
on
this
consent.
My
“protected
health
information”
means
health
information,
including
my
demographic
information,
collected
from
me
and
created
or
received
by
my
physician,
another
health
care
provider,
a
health
plan,
my
employer
or
a
health
care
clearinghouse.
This
protected
health
information
relates
to
my
past,
present
or
future
physical
or
mental
health
condition
and
identifies
me,
or
there
is
a
reasonable
basis
to
believe
the
information
may
identify
me.
I
understand
I
have
a
right
to
review
C.E.
Huang,
M.D.’s
Notice
of
Privacy
Practices
prior
to
signing
this
document.
The
Notice
of
Privacy
Practices
describes
the
types
of
uses
and
disclosures
of
my
protected
health
information
that
will
occur
in
my
treatment,
payment
of
my
bills
or
in
the
performance
of
health
care
operations
of
the
office
of
Dr.
Huang.
The
Notice
of
Privacy
Practices
for
C.E.
Huang,
M.D.
is
also
provided
in
the
office
waiting
room
where
it
is
posted
on
the
wall.
This
Notice
of
Privacy
Practices
also
describes
my
rights
and
C.E.
Huang,
M.D.
duties
with
respect
to
my
protected
health
information.
C.E.
Huang,
M.D.
reserves
the
right
to
change
the
privacy
practices
that
are
described
in
the
Notice
of
Privacy
Practices.
I
may
obtain
a
revised
notice
of
privacy
practices
by
calling
the
office
of
Dr.
Huang
and
requesting
a
revised
copy
to
be
sent
in
the
mail
or
asking
at
the
time
of
my
next
appointment.
X_____________________________________
Signature
of
Patient
or
Personal
Representative
“By signing this document, I am stating I have read
the Notice of Privacy Practices for this office”
_________________________________________________________
Print Name of Patient or Personal Representative
__________________________________________________________
Date
__________________________________________________________
Description of Personal Representative Authority
Texas State Law requires us to get your permission to release any medical information regarding your care, to anyone other than
yourself or your medical insurance company. Please list below persons who you authorize us to release your medical information to:
1) ___________________________________________
__________________________________________
Name
Relationship
2) ___________________________________________
___________________________________________
Name
Relationship
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