PATIENT AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION – HEAR HERE AUDIOLOGY
I understand that as part of my health care, the practice originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment.
I understand that this information serves as:
A basis for planning my care and treatment.
A means of communication among the health professionals who contribute to my care, such as referrals.
A source of information for applying my diagnosis and treatment information to my bill.
A means by which a third-party payer can verify that services billed were actually rendered.
A tool for routine healthcare operations, such as assessing quality and reviewing the competence of staff
We can provide you with a “Notice of Patient Privacy Practices” that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
The right to restrict or revoke the use or disclosure of my health information for other uses or purposes.
The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations.
I request the following restrictions to the use or disclosure of my health information:
Please tell us with whom we may discuss your protected health information:
(Example: spouse (name), children (name(s), other relatives (name(s), friends or caregivers (name(s)_____________________________________________________________________
Messages or Appointment Reminders: ____________________________________________________________________________
May we leave a message at your home using doctor’s/practice name: Yes ( ) No ( )
May we leave a message at your work using the doctor’s/practice name Yes ( ) No ( )
I understand that as part of treatment, payment, or healthcare operations, it may become necessary to disclose health information to another entity, i.e., referrals to other healthcare providers. I consent to such disclosure for these uses as permitted by law.
I fully understand and accept/decline (please circle one) the information of this consent.
Patient/Guardian Signature Date