ACKNOWLEDGMENT AND CONSENT
I understand that Michael
H.
Foust, Ph.D. (referred to below as "This Practice") will use and
disclose health information about me.
I understand that
my health
information may include information both created and received by the
practice,
may be in the form of written or electronic records or spoken words,
and may
include information about my health history, health status, symptoms,
examinations, test results, diagnoses, treatments, procedures,
prescriptions,
and similar types of health‑related information. I understand and agree
that
This Practice may use and disclose my health information in order to:
- make
decisions
about and plan for my care and treatment;
- refer to, consult with, coordinate
among, and manage along with
other health care providers for my care and treatment;
- determine
my
eligibility for health plan or insurance coverage, and submit bills,
claims and
other related information to insurance companies or others who may be
responsible to pay for some or all of my health care and
- perform
various
office, administrative and business functions that support my
physician's
efforts to provide me with, arrange and be reimbursed for quality,
cost‑effective
health care.
I also understand
that I have
the right to receive and review a written description of how This
Practice will
handle health information about me. This written description is known
as a
Notice of Privacy Practices and describes the uses and disclosures of
health
information made and the information practices followed by the
employees, staff
and other office personnel of This Practice, and my rights regarding my
health
information.
I understand that
the Notice
of Privacy Practices may be revised from time to time, and that I am
entitled
to receive a copy of any revised Notice of Privacy Practices. I also
understand
that a copy or a summary of the most current version of This Practice's
Notice
of Privacy Practices in effect will be posted in waiting/reception area.
I understand that I
have the
right to ask that some or all of my health information not be used or
disclosed
in the manner described in the Notice of Privacy Practices, and I
understand
that This Practice is not required by law to agree to such requests.
By signing below, I
agree
that I have reviewed and understand the information above and that I
have
received a copy of the Notice of Privacy Practices.
By:
_______________________________
___________
(Patient)
(Date)
‑OR‑
By:
_______________________________ ___________
(Patient
representative)
(Date)
Description of
Representative's Authority: _____________________________