I have the right to review the Privacy Notice prior to signing the consent. Our office reserves the right to revise the privacy notice at any time. A revised privacy notice may be obtained by forwarding a written request to our privacy officer.
With this consent, our office may call my home or other alternative locations and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out treatment, payment, and health care operations, such as appointment reminders, insurance items, and any calls pertaining to any clinical care, including laboratory test results, among others.
With this consent, our office may mail to my home other or other alternative locations any items that assist the practice in carrying out treatment, payment, and health care operations, such as appointment reminders cards and patient statements.
With this consent, our office may email to my home or other alternative location any items that assist the practice in carrying out treatment, payment, and health care operations, such as appointment reminders cards and patient statements. I have the right to request that our office restrict how it uses or discloses my PHI to carry out treatment, payment, and health care operations. This practice is not required to agree to any requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to allow our office to use and disclose my PHI as set forth in the Privacy Notice to carry out treatment, payment, and health care operations.
I may revoke my consent in writing except to the extent that the practice has already made disclosures reliant upon any prior consent. If I do not sign this consent, or later revoke it, our office may decline to provide treatment to me.