You can copy and paste this in your own word processor. Then just add the information of your practice and make th efew little changes that you want. This will get your form customized and ready for you.
Name of your practice
Address of practice
Tel
Fax
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
Section A: Patient Giving Consent
NAME: ___________________________________________________________________________
ADDRESS: ___________________________________________________________________________
PHONE: ___________________________ E-MAIL: _________________________________
PATIENT OF: _________________________ SOCIAL SECURITY #: _______________________
SECTION B: TO THE PATIENT - PLEASE READ THE FOLLOWING STATEMENTS
Purpose of Consent: By signing this form, you will consent to our use of your protected health information, payment activities and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide to sign this consent. Our Notice provides a description of your treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your p0rotected health information, and of other important materials about your protected health information. A copy of our Notice accompanies this Consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:
CONTACT PERSON: _________________________, Office Manager
ADDRESS: _______________________________(Address of your practice)
TELEPHONE: _________________________
Right to Revoke: You will have the right to revoke this Consent at any time by giving us a written notice of your revocation to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance of this Consent before we received your revocation, and that we may decline to treat you or continue treating you if you revoke this Consent.
SIGNATURE
I, __________________________________ , have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that by signing this Consent form, I am giving my consent to your use of disclosure of my protected health information to carry out treatment, payment activities and health care operations.
SIGNATURE: ____________________________________ DATE: ________________________________________
If this Consent is signed by a personal representative on behalf of the patient, please complete the following:
Personal Representative’s Name: ___________________________________________________________________________
Relationship to Patient: __________________________________________________________________________________
YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT
INCLUDE COMPLETED CONSENT IN THE PATIENT’S CHART