Hipaa Consent Forms - Wellstar Health System printable pdf download

Patient Authorization for Use and Disclosure of Protected Health Information

The information on this form is used to facilitate our communications to you as we strive to provide you with excellent service.

The provision of this information is optional.

Patient Information

(please print clearly)

Last Name

First Name

Middle Initial

Date of Birth

(Month/Day/Year)

Street Address

Apt. #/P.O. Box # (Please include complete mailing address)

Medical Record #/Social Security# (optional)

City

State

Zip Code

Primary Contact Number

If we cannot reach you at the telephone number listed above, WellStar may contact you (including leaving messages)

regarding appointments or normal lab results at the following number(s):

Business Number

Cell Phone Number

Other Phone Number

I authorize the WellStar Medical Group to disclose Protected Health Information to the following persons:



Spouse:

Name

Phone Number



Child(ren):

Name

Phone Number

Name

Phone Number



Other:

Name

Phone Number

Information to be disclosed



All Medical Information

Laboratory Results

All Billing/Account Information

Authorization Statement:

I understand that Protected Health Information (PHI) used or disclosed pursuant to this Authorization may be

subject to re-disclosure by the recipient and no longer protected by Federal or State Law. I understand that I have the right to revoke this

authorization at any time. I understand that in order to revoke this authorization, I must do so in writing and present my revocation to the

WellStar location where I received care. I understand that the revocation will not apply to information that has already been used or disclosed in

response to this authorization. I understand that WellStar cannot require me to sign this authorization as a condition of treatment unless the

provision of health care by WellStar is solely for the purpose of creating PHI for disclosure to a third party legally authorized to receive such

information. I understand that I will be given a copy of this authorization.

Signature/Date:

(date authorization signed by patient or Legal Guardian/Personal Representative) _________________________________

Month/Day/Year

___________________________________________________________

___________________________________________________

Print Patient Name or Name of Legal Guardian/Personal Representative

Signature of Patient or Legal Guardian/Personal Representative

Indicate relationship to patient (required)

Expiration Date:

This authorization is valid until written notice is provided to revoke this authorization.

Hipaa Consent Forms - Wellstar Health System

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