Privacy Policy and Information Practices Patient Rights Statement

Use and Disclosure of Health Information Consent Form

Consent: By signing this form, you do consent to our use and disclosure of your personal health information to carry out treatment, payment activities and other healthcare operations required by this office. You acknowledge you are aware of our need to share your protected personal health information and have received your patient rights notification explaining in detail our office Privacy Policy and Information Sharing Policy.

Right to Revoke: You have the right to revoke this consent at any time by giving us written notice. We will honor this request the day we receive your written notice. Please understand that it will not affect any action taken before we received your revocation and we may decline to treat you or to continue treating you if you revoke this consent.

Changes to Privacy Practices: We reserve the right to change our privacy practices described in our Patients Rights Privacy Policy and Information Practices. If we change our practices we will issue a revised Patient Rights Privacy Policy and Information Practices statement.

Patient Responsibility: We request timely notification of any changes to your personal information we maintain for you, such as but not limited to, health history information, address, telephone number, active insurance information, and change in employer.

I, _________________________________, have received a copy of the Dr. Boss’s office’s Privacy Policy and Information Practices. I have read and understand the above information. In understand that by signing this form I am giving my consent to use and disclose my protected health information to carry out treatment, payment activities and health care operations.

_________________________________________ __________________ ________________

Patient Signature Date Witness

Consenting Patient Information:

Name: __________________________________ D/O/B ________________

Address: ______________________________________________________________________

Street City State Zip

Telephone: Home_____________________ Work__________________ Cell________________

Minor children also covered by this consent:

Name: ____________________________________ D/O/B ________________