File - Cornerstone Women`s Care

Document technical information

Format pdf
Size 81,7 kB
First found окт 9, 2016

Document content analysis

Language
English
Type
not defined
Concepts
no text concepts found

Places

Transcript

Misti Bartell, DO | Sylvia Castro, MD | M. Lance Holemon, MD
Erica Montes, MD | Tina Pelopida, MD, MPH
Patient Consent for Use and Disclosure
of Protected Health Information
With my consent, Cornerstone Women’s Care P.C., may use and disclose protected health information (PHI) about me to
carry out treatment, payment and health care operations (TPO). Please refer to Cornerstone Women’s Care, P.C. Notice of
Privacy Practices for a more complete description of such uses and disclosures.
I have the right to review the Notice of Privacy Practices prior to signing this consent. Cornerstone Women’s Care, P.C.
reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained
by sending a written request to Cornerstone Women’s Care, P.C., Privacy Officer at 15255 N 40th St. #105, Phoenix, AZ 85032.
With my consent, Cornerstone Women’s Care, P.C. may call my home or other designated location and leave a message
on voice mail or in person in reference to any items that assist the practice in carrying our TPO, such as appointment
reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others. I consent,
in order for Cornerstone Women’s Care, P.C. to service my account or to collect any amounts I may owe, to let them contact
me by telephone at any telephone number associated with my account, including wireless telephone numbers, which could
result in charges to me. I may be contacted by sending text messages or e-mails, using any e-mail address I provided to
Cornerstone Women’s Care, P.C. Methods of contact may include using pre-recorded/artificial voice messages and/or use
of an automatic dialing device, as applicable.
With my consent, Cornerstone Women’s Care, P.C. may mail to my home or other designated location any items that assist
the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request
that Cornerstone Women’s Care, P.C. restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not
required to agree to my request restrictions, but if it does, it is bound by this agreement.
We participate in an organized health care arrangement consisting of greater Phoenix metropolitan area hospitals as
well as physicians who have medical staff privileges at one or more of these hospitals. Participants in this arrangement
work together to improve the quality and efficiency of the delivery of healthcare to their patients. As a participant in this
arrangement, we may share your PHI with other members of this arrangement for purposes of treatment, payment or the
health care operations of this organized health care arrangement.
By signing this form, I am consenting to Cornerstone Women’s Care, P.C. use and disclosure of my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my
prior consent. If I do not sign this consent, Cornerstone Women’s Care, P.C. may decline to provide treatment to me.
Advance Directives information has been made available to me.
Patient’s Right’s & Responsibilities have been made available to me.
I authorize this office to discuss my medical care or treatment with the following person(s):
Name: ______________________________________________ Relationship:________________ Patient Initials: _ ____
Name: ______________________________________________ Relationship:________________ Patient Initials: _ ____
____________________________________________________________________________________
Signature of Patient or Legal Guardian
Date
____________________________________________________________________________________
Print Name of Patient or Legal Guardian
15255 N. 40th Street • Suite 105 • Phoenix, AZ 85032 • phone: 602.867.2690 • fax: 602.404.1904
C o r n e r s t o n e W o m e n s C a r e . c o m — Embracing Women’s Health Care

Similar documents

×

Report this document