Healthcare PN Document

Healthcare PN Document

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History

Notice of Privacy Practices & Patient Notification

The facility maintains a Notice of Privacy Practices that describes how protected health information (PHI) may be used and disclosed and how patients may access this information. PHI may be used for treatment, payment, and healthcare operations, including coordination of care, insurance claims, quality assessment, and training. PHI may be disclosed when required by law, for public health activities, to avert a serious threat to health or safety, or to legal authorities as authorized by law.

Patient Rights: You have the right to inspect and obtain a copy of your medical record, request amendment, request restriction on certain uses and disclosures, request confidential communications, and receive an accounting of disclosures. Requests must be made in writing; the facility will respond in accordance with applicable law. The facility may deny certain requests as permitted by law.

Acknowledgment: By signing below you acknowledge that you have been provided access to the Notice of Privacy Practices. Signing this form does not authorize disclosures beyond those described in a separate written authorization.

Authorization to Release Medical Records (Optional)

I authorize the facility to disclose my protected health information to the following person(s) or organization(s) for the purposes indicated below.

Expiration of Authorization (if any): . If no date is provided, this authorization will expire one year from the date signed unless otherwise required or permitted by law.

I understand that information disclosed pursuant to this authorization may be redisclosed by the recipient and may no longer be protected by federal privacy regulations. I may revoke this authorization at any time by submitting a written revocation to the facility, except to the extent that action has already been taken in reliance on this authorization.

Communications Preferences

I consent to receive appointment reminders and routine communications via text message to the phone number provided.

I consent to receive appointment reminders and routine communications via email to the address provided.

Certification and Acknowledgment

By signing below I certify that the information I have provided on this form is true and correct to the best of my knowledge. I acknowledge that I have been given access to the Notice of Privacy Practices and that I understand my rights regarding my protected health information as described above. I understand that I may refuse to sign this acknowledgment and that refusal will not affect my ability to obtain treatment.

If signed by a personal representative or guardian, indicate relationship:

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