Patient Consent Form
PROSPECT PEDIATRICS PA
Patient Consent for use and disclosure of Protected Health Information
I have the right to review the Notice of privacy Practices prior to signing this consent. Prospect Pediatrics PA reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Director Office Operations Prospect Pediatrics PA
With this consent, Prospect Pediatrics PA may call my home or other alternative location and leave message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.
With this consent, Prospect Pediatrics PA may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”
With this consent, Prospect Pediatrics PA may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patients statements. I have the right to request that Prospect Pediatrics PA restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to allow Prospect Pediatrics PA to use and disclose my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Prospect Pediatrics PA may decline to provide treatment to me.
Patient/Guardian must be provided with a signed copy of this authorization