| Consent for Purposes of Treatment, Payment and Healthcare Operation ________________________________________________________________ _________________________________________________________________ I consent to the use or disclosure of my protected health information by Athens Primary Care for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations Athens Primary Care, I understand that diagnosis or treatment of me by Dr. Samuel C. Griffin, Dr. Mary T. Bond, Dr. Mary Kim, Dr. Ken Park, and Bert Stauff, FNP may be conditioned upon my consent as evidenced by my signature on this document. I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Athens Primary Care is not required to agree to the restrictions that I may request. However if Athens Primary Care agrees to a restriction that I request, the restriction is binding on Athens Primary Care and Dr. Samuel C. Griffin, Dr. Mary T. Bond, Dr. Mary Kim, Dr. Ken Park, and Bert Stauff, FNP. I have the right to revoke this consent, in writing, at any time, except to the extent that Dr. Samuel C. Griffin, Dr. Mary T. Bond, Dr. Mary Kim, Dr. Ken Park, and Bert Stauff, FNP or Athens Primary Care has taken action in reliance on this consent. My “protected health information” means health information, including any demographic information collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. I understand I have a right to review Athens Primary Care’s Notice of Privacy Practices prior to signing this document. The Athens Primary Care’s Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of the Athens Primary Care’s Practice. The Notice of Privacy Practices for Athens Primary Care’s Practice is also provided for review on the interior wall of front office check out and on the Athens Primary Care’s website at www.athensprimarycare.com. This Notice of Privacy Practices also describes my rights and the Athens Primary Care’s duties with respect to my protected health information. Athens Primary Care reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by accessing the Athens Primary Care’s website, calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment. ______________________________________ Signature of Patient or Personal Representative ___________________________________ Name of Patient or Personal Representative _________________________ Date _________________________________________ Description of Personal Representative’s Authority |
