Healthcare Digizime Form

HEALTHCARE DIGIZIME FORM

Patient Information

Patient Name:

Date of Birth:    Gender: Male   Female   Other/Prefer not to say

Emergency Contact

Insurance Information

Medical History

Are you pregnant or breastfeeding?   Yes   No

Digital Imaging, Telehealth and Electronic Communications Consent

I hereby authorize the collection, creation, storage and use of digital images, video, audio, and other electronic health information (collectively, Digital Health Data) collected in connection with my care. Purpose: diagnosis, treatment, clinical documentation, billing, quality assurance and continuity of care. Recipient: treating providers and authorized personnel involved in my care.

Risks and limitations: I understand that transmission and storage of Digital Health Data involve risks of interception, unauthorized access, alteration, or disclosure. While reasonable safeguards are employed, absolute confidentiality cannot be guaranteed. Electronic communications (including text messages and email) may not be secure and may be routed through third-party networks.

Benefits: Use of Digital Health Data and telehealth modalities can improve access to care, allow remote consultations, and expedite clinical decision-making. Refusal to consent will not affect my ability to receive treatment, but may limit the use of telehealth and certain remote services.

Email communications regarding appointments, results, and treatment   SMS/text messaging for reminders and brief clinical messaging   Telephone voice calls

Authorization to Release Digital Records

I authorize the disclosure of my Digital Health Data described above to the following recipient(s). I understand this authorization is voluntary and that my records may include sensitive information (behavioral health, substance use, reproductive health) which will be released unless I specifically restrict it below.

Digital images, radiology studies, diagnostic images   Electronic health record notes, problem list, medications   Laboratory results   Complete medical record

Authorization Term, Revocation, and Fees

Expiration date of this authorization:

I understand I may revoke this authorization at any time by providing a written notice to the health information custodian identified below. Revocation will not apply to disclosures already made in reliance on this authorization. I understand that a reasonable fee may be charged for copying and transmitting records where permitted by law.

HIPAA Acknowledgment and Patient Rights

I acknowledge that I have been provided the opportunity to review the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights regarding that information. I understand I may request restrictions, inspect and receive a copy of my records, and request amendment of my records in accordance with applicable law.

By signing below I certify that I have read and understand this authorization, that the information I have provided on this form is accurate to the best of my knowledge, and that I authorize the uses and disclosures described herein. I understand that signing this form is voluntary and will remain in effect until the expiration date above unless revoked earlier in writing.

Certification

I certify under penalty of perjury that I am the patient or authorized personal representative of the patient and that I have authority to execute this authorization. If I am signing as a personal representative, I attest that I am legally authorized to act on behalf of the patient and will provide documentation of such authority upon request.

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