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Required Annually

CONSENT TO RELEASE PERSONAL HEALTH INFORMATION (PHI)

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our notice before signing this consent and prior to any service being provided to you by the Practice. The Practice reserves the right to change the Notice of Privacy policies. If we change our notice, you may obtain a revised copy by sending a letter to the Practice’s HIPAA Officer or by asking the provider’s receptionist. You can also obtain a copy on the clinic’s website at www.ncdhp.com.

By signing this form, you acknowledge that you have been given an opportunity to read the clinic’s Notice of Privacy Practices prior to any service being provided to you by this Practice, and you consent to the use and disclosure of your medical information to other healthcare providers involved in your care and for treatment, payment and healthcare operations. You have the right to revoke this consent in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health (HITECH).

I authorize Physicians/staff of DIGESTIVE HEALTH PARTNERS to release information pertaining to my condition and/or care to those individuals listed below:

List
Name
Date of Birth
Relationship
Contact Phone Number
 
Digestive Health Partners physicians and staff may contact me in the manner: (Check all that apply)
Preferred Method of Contact (please check)(Required)
I hearby acknowledge that I can request a copy of this office's Notice of Privacy Practices.
MM slash DD slash YYYY
WE CANNOT SPEAK TO ANYONE YOU HAVE NOT LISTED ABOVE.
THIS FORM MUST BE COMPLETED AND SIGNED