Patient Consent for Use and Disclosure of Protected Health Information
HIPAA Privacy Regulation
Federal law, the Health Insurance Portability and Accountability Act of 1996, authorized the Department of Health and Human Services to adopt new rules to protect patient privacy.
Notification is therefore given that the office of Optimum Health Medical Center (OHMC) will not reveal to any person information about you or about a family member (i.e. name, address, Social Security number as well as other health information) without your permission. Your information will never be sold, or listed for the purpose of advertisement solicitation or fund raising. It is however understood, that with your consent, OHMC may use and disclose protected health information (PIH) about me to carry out treatment, payment and healthcare operations (TPO).
With my consent, OHMC may call my home or other designated location and leave a 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 call pertaining to my clinical care, including laboratory results among others.
With my consent, OHMC may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards, patients statements as long as they are marked “Personal and Confidential.
With my consent, OHMC may email to my home or other designated location any items that assist the practice in carrying out TPO. However, the practice is not required to agree mu requested restrictions, but if it does, it’s bound by this agreement.
Your personal information will be necessary and used in the context of your patient care including, but not limited to,
- Patient registration
- Procurement of medical records from former physicians
- Converse with colleagues for opinions/care
- Insurance: verifications, billing, paper and wire (including e-mail & fax transmissions)
- Insurance company follow-up or interaction with billing services relating to patient care
- Pursuit of collections for unpaid bills
- Hospital workers, nurses, aids and medical records departments
- Emergency officials, Paramedic, Fire personnel, Emergency room physicians, nurses or technicians
- Designated personal religious representatives
- Our office staff
- Pharmacists, drug program personnel/workers
- Completion of disability forms
- Computer and electronically stored information, i.e., related business vendor and service personnel
This constitutes an abridged version of our HIPPA Privacy Regulation Policy. I authorize the release of this necessary information.
Patient Signature Date
Please clearly print first and last name here: _______________________________________