EFTA00313932.pdf

East Side II Itau i'1.1.(' ?Hest% 1). Wolff 1 1.1). l'Ii.1). 170 K n- St., Nen I (irk %I 100 7:$ HIPAA PRIVACY NOTICE which describes the Practices • I acknowledge that I have been given • copy el the Pratte:a 'HIPAA Privacy Notice also describe* how the Practice may use Obligations to ensure the privacy of my Stith Inlorrnatban. The HIPAA Privacy Notice I knew that I have the right to renew the and disclose my health information for treebnent PaYannt and health care operations. is required to maintain the privacy of Practices/URSA Privacy Notice and to ask questions about It. I understand the Practice my health information in accordance with the terms of its HIPAA Privacy Notice. and that I can receive a copy of the • I further acknowledge that the Practice can change its HIPAA Privacy Notice In the future. Practice's current Privacy Notice at any time by contacting the Privacy Offcer. of my health information for • I understand that I have a right to request that the Practice restrict its uses and disclosures Practice, these restrictions will be binding treatment, payment, or health care operabons. If my restrictions are acceptant by the restrictions. on the Practice. I also understand that the Practice is not required to agree to my requested for treatment, payment or health • Ids not request any restrictions on the Practices use or disclosures of my health Information care operations. T'; (initial). disclosures of my health information for treatment, • I gig request speCIfiCtilritrictlorts, as fisted below, on the Practice's use or payment or health Care operations. and • By signing this lore'.I consent to the Practice's use end disclosure of my health informationfor treatment. payment time d writing, but d I do, my revocation healthCare operations. I understand that I have the right to revoke this consent at any win not influence any actions the Practice hat ready taker in reliance on this consent Au SI aption to Obtain or Release Medical Records from Medical Provident medical records specifically related to my current I hereby authorize East Side Medical Radiology PL LC to obtain any and ail medical care to me in relation to my condition from any physician, hospital, or other head., care professional that has provided current condition In the peat. my care to the following I also authorize the Practice to release any and all medical records. physically or verbally, concerning specified parties: Referring Physician Da. ... ei -deplixet. KgmeeK Insurance Company, etedirare, Modleekt, lltird Party Consent Required Consent Required Administrator, Managed Care Company Additions Party Mame Relationship to Patient 1• 2. 3. 4. lk Authorization to Obtaintor Reins* Medical Information to Individualtram_gv Members Portability Act of 1996 (HIPAA), in order fee In accordance with Federal government privacy rules I mpierrienled through the Healthcare individuals that you despnate, we your physician or staff of the Practice to discuss your condition with members of your I amuy or other authorization prier to doing so. In tho event of a critical episode or d you are unable to give your authorization due to the must obtain your Seventy o91 your medical conditions, the law stipulates that these rules may be waived (initial) I authorize the Practice to release any or all Information, In any form of communication, condommM my medical cam es set forth above. /,--- ...,.....------- Patient's Signature-- I Print Patient's Name 5;- FT:: Ai*N cran?-it.1 Date: :ThtNI - I 86)-01S) EFTA00313932