South Bay Family Medical Group
12345 Anytown Lane, Suite 123, Torrance, CA 99999 (310) 555-5555 fax (310) 999-9999 Patient Consent Form (Must Be Completed and Returned By Patient Prior To Treatment) To the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations I, , (Account Number: ) understand that as part of my health care, South Bay Family Medical Group 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:
I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
I understand that South Bay Family Medical Group is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations. I further understand that South Bay Family Medical Group reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should South Bay Family Medical Group change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S. mail or, if I agree, email). I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax.
FOR OFFICE USE ONLY |