Healthcare Confidentiality Statement

HEALTHCARE CONFIDENTIALITY STATEMENT

Patient Name:    Date of Birth:    Gender:

CONTACT & INSURANCE

MEDICAL HISTORY (RELEVANT)

CONFIDENTIALITY STATEMENT

The healthcare provider, its employees, agents and contractors will protect the confidentiality of my protected health information (PHI). PHI will be used and disclosed only as required for treatment, payment, and healthcare operations, and otherwise as permitted or required by law. I acknowledge that I have received and reviewed a written notice describing the provider’s privacy practices and patient rights regarding PHI.

By signing this document I authorize disclosures of my PHI as described in this statement and in the provider’s privacy notice. I understand that disclosures made in accordance with this authorization may include information regarding medical records, diagnoses, treatment plans, medications, and billing records.

PERMITTED DISCLOSURES (CHECK ALL THAT APPLY)

Use and disclosure for treatment, payment, and healthcare operations.

Release information to my emergency contact listed above.

Release information to family member or caregiver for care coordination. If selected, name(s) and relationship(s):

LIMITS TO CONFIDENTIALITY

I understand that confidentiality is not absolute. PHI will be disclosed without my authorization when required or permitted by law, including but not limited to: mandatory reporting of child, elder or dependent adult abuse; threats of harm to self or others; court orders, subpoenas, or other legal processes; public health reporting of certain communicable diseases; and situations involving the collection of fees or fraud investigations.

I acknowledge that the provider will make reasonable efforts to limit disclosures to the minimum necessary for the stated purpose.

ELECTRONIC COMMUNICATIONS & MESSAGES

I consent to the provider contacting me by the following methods for appointment reminders, treatment information, and billing communications (check all that apply). I understand that electronic communications may carry some risk to privacy.

Telephone calls to the number on file

Text messages/SMS to the number on file

Voicemail messages left at the phone number on file

AUTHORIZATION TO RELEASE INFORMATION (OPTIONAL)

I authorize the release of my PHI to the person(s) named below for the purposes specified. This authorization is voluntary and I may revoke it in writing except to the extent action has already been taken in reliance upon it.

PATIENT ACKNOWLEDGMENT

I acknowledge that I have received and had the opportunity to review the provider's privacy notice describing uses and disclosures of PHI and my rights under applicable law.

I understand that I may revoke authorizations in writing, except where disclosures have already been made in reliance on my prior authorization, and that revocation does not apply to information released pursuant to other lawful disclosures.

I understand that I may request restrictions on certain uses and disclosures and that the provider will consider such requests; however, the provider is not required to agree to restrictions except where required by law.

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