Healthcare Clinical Use Acknowledgement

HEALTHCARE CLINICAL USE ACKNOWLEDGEMENT

Patient Name:    Date of Birth:    Medical Record/Account #:

Patient Information

Gender: Male Female Other Prefer not to say

Insurance Information

Medical History Summary

Acknowledgement of Clinical Use

I acknowledge that clinical data, medical images, biological specimens, and related information created or obtained in the course of my care may be used by the healthcare organization for: clinical care and consultation, quality assurance and performance improvement activities, clinician education and training, internal audits, and limited clinical research and evaluation activities conducted under institutional oversight and applicable law.

Uses may include review by healthcare personnel, presentation in educational forums with identifying information removed whenever feasible, and analysis to improve clinical processes. Such uses are intended to advance patient care and provider competency and do not alter the primary purpose of my clinical treatment.

I understand that:

• Where possible, identifying information will be removed (de-identified) before non-clinical uses; however, there is a minimal risk of re-identification.
• My decision regarding use of de-identified information will not affect my access to medical treatment or services.
• I may, to the extent permitted by law and institutional policy, place limitations on certain non-treatment uses by providing written notice to the health information contact listed below.

Please indicate your selections below:

I acknowledge and consent to the use of my de-identified clinical information and specimens for the purposes described above.

I consent to the use of my identifiable clinical information or specimens for internal quality improvement and care coordination purposes only (not for research involving publication without separate authorization).

I decline non-clinical use of my identifiable information or specimens. I understand this may limit certain internal educational or research activities that would otherwise include my information.

Rights and Privacy Acknowledgement

I acknowledge that I have been provided the health care organization's Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights with respect to that information.

I acknowledge receipt of the Notice of Privacy Practices.

To withdraw or modify this acknowledgement, I understand I must submit a written request directed to the Health Information Management or Privacy Office identified by the healthcare organization. Withdrawal will not apply to uses or disclosures already made in reliance on this acknowledgement prior to receipt of the revocation.

Patient Certification

By signing below I certify that I am the patient identified above or the authorized personal representative of the patient; that I have read and understand this Clinical Use Acknowledgement; that my questions (if any) have been answered; and that I authorize the uses and acknowledgements I have selected above.

Sign Now