I, (Type your name below)
(Parent or Guardian), understand that as part of my health care, Brian Thornburg DO PA originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information serves as:
I understand and have been provided with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
I understand that Brian Thornburg DO PA is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon, I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.
I further understand that Brian Thornburg DO PA reserves the right to change the notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should Brian Thornburg DO PA, P.A. change the notice, they will send copy of any revised notice to the address. I’ve provided, (whether U.S mail or if I agree email).
I wish to have the following restrictions to use or disclosure of my health information:
I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosure via fax.
I fully understand and accept the terms of this consent
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law.
You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.
You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to treatment for disease, injury or well care at Brian Thornburg DO PA for you or your child. The information collected during this treatment is protected health information and you further consent to the use and disclosure of protected health information about you or your child for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 and 2013.
The patient understands that: