Consent to Treat

Please fill out this form as completely as possible. It will be sent securely to our office.

CONSENT FOR USE OF DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR PAYMENT, TREATMENT, MEDICATION HISTORY, AND HEALTHCARE OPERATIONS

By signing below, you hereby consent for Fairhope Pediatrics, Inc., to use or disclose information about yourself (or another person for whom you have the authority to sign) that is protected under federal law, for the sole purposes of treatment, payment, accessing/reviewing medication history, and healthcare operations. You may refuse to sign this consent form.

You should read the Notice of Privacy Practices for PHI available at the front desk and on our web site (English | Español) for your review before signing this consent. The terms of the notice may change from time to time, and you may always get a revised copy of it by asking the Privacy Officer for Fairhope Pediatrics, Inc.

You have the right to request that Fairhope Pediatrics, Inc., restrict how PHI is used or disclosed to carry out treatment, payment, or healthcare operations. Fairhope Pediatrics, Inc., is not required to agree to requested restrictions, however, if Fairhope Pediatrics, Inc., agrees to your requested restrictions, the restriction is binding on it.

Information about you is protected under the federal law, and you have the right to revoke this consent, unless we have taken action in reliance on your authorization (as determined by our Privacy Officer). By signing below, you recognize that the protected health information used or disclosed pursuant to this consent may be subject to re-disclosure by the recipient and may no longer be protected under federal law.

Q1*
Please check the following if applicable:
- You may call my home and leave a message with someone or on an answering machine if I am not available.
- You may call my place of employment and leave a message on an answering machine or with someone if I am not available.
- You may call my cell phone and leave a message on my answering machine if I am not available.
- You may communicate confidential information to me, including invoices for services, to the address and/or phone numbers that have been listed in my patient information. If no, please indicate the address or phone number that we may use:
Other address or phone number
Signature
By signing below, you recognize that the protected health information used or disclosed pursuant to this consent may be subject to re-disclosure by the recipient and may no longer be protected under federal law.
Patient Name*
DOB*
Parent/Guardian Name*
Relationship*
Parent/Guardian Signature*
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Date
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

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