Patient Health Information Authorization Agreement and Consent
We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we require you to read and sign this form stating that you understand and agree with how your health information will be used, your authorization to use that information, and your rights regarding that information.
Notice of Privacy Practices
I acknowledge that I have been provided with this office's Notice of Privacy Practices. I understand that it provides a complete description of the uses and disclosures of my health information. I understand that a copy of the Notice of Privacy Practices is also available at the front desk as well as https://www.sfveincenter.com.
Authorization for the Disclosure of PHI for Treatment, Payment, or Healthcare Operations
I understand that as part of my healthcare this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as:
- a basis for planning my care and treatment.
- a means of communication among the health professionals who may contribute to my healthcare.
- a source of information for applying my diagnosis and surgical information to my bill.
- a means by which a third-party payer can verify that services billed were actually provided.
- a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.
I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I authorize the disclosure of my Protected Health Information as specified above.
Consent to the Use and Disclosure of PHI for Treatment, Payment, or Healthcare Operations
I understand that:
- I have the right to review this facility's Notice of Information practices prior to signing this consent.
- This facility, reserves the right to change the notice and practices.
- I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that this facility is not required by law to agree to the restrictions requested.
- I may revoke this consent in writing at any time, except to the extent that this facility, has already taken action in reliance thereon.
- It is this facility's procedure to share Protected Health Information with labs, x-rays, consulting physicians, and hospitals. We will call the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary Protected Health Information for each transaction.
Open Payments Database
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.