Patient Last Name | Patient First Name (Printed) | MI | Date of Birth (MM/DD/YYYY) |
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Do you want to designate a family member or other individual with whom the provider may discuss your medical condition? If yes, whom?I give permission for my Protected Health Information to be disclosed for purposes of communicating results, findings and care decisions to the family members and others listed below:
Name | Relationship | Contact Number | |
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1. | |||
2. | |||
3. |
Patient/Representative may revoke or modify this specific authorization and that revocation or modification must be in writing.
I agree the Provider or an agent of the Provider or an independent physician’s office may contact me for the purposes of scheduling necessary follow-up visits recommended by the treating physician.
I consent to photographs, digital or audio recordings, and/or images of me being recorded for patient care, security purposes and/or the practice’s/clinic’s health care operations purposes (e.g., quality improvement activities). I understand that the practice/clinic retains the ownership rights to the images and/or recordings. I will be allowed to request access to or copies of the images and/or recordings when technologically feasible unless otherwise prohibited by law. I understand that these images and/or recordings will be securely stored and protected. Images and/or recordings in which I am identified will not be released and/or used outside the facility without a specific written authorization from me or my legal representative unless otherwise permitted or required by law.
If at any time I provide an email address or cellphone number at which I may be contacted, I consent to receiving unsecure instructions and other healthcare communications at the email or text address I have provided or you or your EBO Servicer have obtained, at any text number forwarded, or transferred from that number. These instructions may include, but not be limited to: post-procedure instructions, follow-up instructions, educational information, and prescription information. Other healthcare communications may include, but are not limited to, communications to family or designated representatives regarding my treatment or condition, or reminder messages to me regarding appointments for medical care. Note: You may opt out of these communications at any time. The practice/clinic does not charge for this service, but standard text messaging rates or cellular telephone minutes may apply as provided in your wireless plan (contact your carrier for pricing plans and details).
Note: This clinic uses an Electronic Health Record that will update all your demographics and consents to the information that you just provided. Please note this information will also be updated for your convenience to all our affiliated clinics that share an electronic health record in which you have a relationship.
I hereby permit practice/clinic and the physicians or other health professionals involved in the inpatient or outpatient care to release healthcare information for purposes of treatment, payment, or healthcare operations.
I certify that I have read and fully understand the above statements from all pages and consent fully and voluntarily to its contents.
Patient/Representative Signature | Relationship to Patient (self, parent, legal guardian/representative, etc) | Date |
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Name | Relationship |
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Updated: October 8, 2018 v7 replacing 1/05/2018, 12/20/2016, 04/22/2016, 10/28/2015, 06/12/2015, 11/21/2013
A photocopy of this consent shall be considered as valid as the original.