Patient Consent Form - Midlothian Medical & Sports Center TX

HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

Our Notice of Privacy Practices provides information about how Midlothian Medical & Sports Center may use and disclose your protected health information and when we need your written authorization to do so. This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards

Name of patient

Date of birth

1. My Authorization

I authorize to use or disclose the following health information:

Name

All of my health information

My health information relating to the following treatment or condition:

My health information covering the period of healthcare from

Start Date

End Date

Other

The above party may disclose this health information to the following recipient:

Name/Organization:

Phone/Mobile

Fax

Email

The purpose of this authorization is (check all that apply):

At my request

To authorize the using or disclosing party to communicate with me for marketing purposes when they receive payment from a third party to do so.

To authorize the using or disclosing party to sell my health information. I understand that the seller will receive compensation for my health information and will stop any future sales if I revoke this authorization.

Other

This authorization ends:

On (Date):

When I am no longer a patient of the practice

When the following event occurs:

On (Date)

Events

2.My Rights

I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party. I understand that uses and disclosures already made based upon my original permission cannot be taken back. I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards. I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization. I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.

Signature of Patient:

Sign Here

Date

If the patient is a minor or unable to sign please complete the following:

Patient is a minor

Patient is unable to sign because

Patient age if he or she is minor

Reason for patient why he can't able to sign:

Authorized Representative Signature:

Sign Here

Date

Name of Representative:

Authority of representative to sign on behalf of patient:

Parent

Legal Guardian

Court Order

Other

Other:

3. Notice of Privacy Practices

The signature below indicates that I have been provided with a copy of the Notice of Privacy Practices for the authorized party listed above and have read and understood its content.

Signature of Patient or Authorized Representative:

Sign Here

Date / Time

Patient's Consent Form

HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

1. My Authorization

2.My Rights

3. Notice of Privacy Practices