PATIENT CONSENT FOR USE AND DISCLOSURE OF
PROTECTED HEALTH INFORMATION (PHI)
With my consent, Advance Pediatrics, PLLC may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to Advance Pediatrics, PLLC’s Notice of Privacy Practices for a more complete description of such uses and disclosures.
I have the right to review the Notice of Privacy Practices prior to signing this consent. Advance Pediatrics, PLLC reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Advance Pediatrics, PLLC, Attn: Practice Manager at 9836 WYEARLING ROAD F-1300 PEORIA AZ 85383
With my consent, Advance Pediatrics, PLLC may call my home phone or cell phone on file or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my child’s clinical care, including laboratory results among others.
With my consent, Advance Pediatrics, PLLC may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.
I have the right to request that Advance Pediatrics, PLLC restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to Advance Pediatrics, PLLC’s use and disclosure of my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Advance Pediatrics, PLLC may decline to provide treatment to me.