Patient Health Information Authorization Agreement and Consent
We want you to know how your Patient Health Information (PHI) is used in this office and your rights. Before any health care operations, please read and sign to confirm you understand and agree to our use of PHI, your authorization, and your rights.
Notice of Privacy Practices
I acknowledge receipt of this office's Notice of Privacy Practices describing uses and disclosures of my health information. A copy is available on request and at https://www.sfveincenter.com.
Authorization for the Disclosure of PHI for Treatment, Payment, or Healthcare Operations
I understand this facility maintains records of my history, symptoms, examinations and tests, diagnoses, treatment, and plans for future care. This information serves as:
- a basis for planning my care and treatment,
- a means of communication among clinicians involved in my care,
- information for billing and benefit verification, and
- a tool for routine operations (quality assessment and competence review).
I understand that PHI may be shared (minimum necessary) with laboratories, imaging centers, consulting physicians, hospitals, pharmacies, and payers for TPO. I authorize the disclosure of my PHI as specified above.
Consent to the Use and Disclosure of PHI for Treatment, Payment, or Healthcare Operations
- I may review the Notice before signing and request restrictions; the facility is not required by law to agree.
- The facility may change its Notice and practices; a copy is available on request.
- I may request confidential communications (alternate phone or address).
- I may revoke this consent in writing at any time, except to the extent action has already been taken in reliance on it.
AI-Assisted Documentation (Chart Notes)
Clinicians may use AI tools to help draft portions of my chart from information I provide (which may include PHI and, when applicable, audio). A licensed clinician reviews, edits, and approves all notes; AI does not make clinical decisions. I may decline AI-assisted documentation at any time without affecting my care.
Open Payments Database
The Open Payments database lets the public search payments made by drug and device companies to physicians and teaching hospitals: https://openpaymentsdata.cms.gov.
Medical Board of California – Notice & Acknowledgment
Physicians are licensed and regulated by the Medical Board of California. To check a license or file a complaint: https://www.mbc.ca.gov · [email protected] · (800) 633-2322.
