Hipaa Consent Forms - Wellstar Health System (Page 3 of 3) in pdf

Last Name: ______________________

First Name: _____________________ DOB: _____________

E-Mail Address: __________________________________________________________

It is the goal of WellStar East Paulding Primary Care Center to provide excellent healthcare with both

respect for your privacy and your time. During office visits, it may be necessary to have lab work or

other diagnostic tests performed either in our office or at an outside facility. If our provider feels that

your results warrant further explanation and we are unable to contact you, we must have an alternate

means of contacting you. In compliance with HIPAA laws, our office may only divulge the results of

any test(s) to the patient, or parent/guardian of a minor under the age of 18, unless you, “the patient”

specify otherwise.

Please indicate below the method in which you prefer to be contacted:

Letter sent to your home address: ___________________________________________________________

Call my home number: (______) _______________________________

Call my cell number: (______) ________________________________

Call my work number: (______) _______________________________

ALL OF THE ABOVE

If granting permission for our office to contact you by phone, may we leave a detailed message on your

voicemail and/or answering machine, regarding any test(s) results and/or account information?

Yes

May our office speak with anyone else other than you (i.e. spouse, adult children, etc) regarding

results, prescriptions, billing, referrals or any other healthcare related information?

Yes

If permissible, please list those who we may speak with on your behalf:

Name: _________________________________

Relationship: _________________________

Name: _________________________________

Relationship: _________________________

Name: _________________________________

Relationship: _________________________

Patient/Guardian Signature: __________________________________

Date: _________________

Hipaa Consent Forms - Wellstar Health System Page 3