Lone Peak Primary Care - HIPAA Acknowledgment and Consent Form

Lone Peak Primary Care
Patient HIPAA Acknowledgment and Consent Form
Patient Name:
Date of Birth:
______ (Patient initials) Notice of Privacy Practices. I acknowledge that I have received the practice’s Notice of Privacy
Practices, which describes the ways in which the practice may use and disclose my healthcare information for its treatment,
payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the
Privacy Officer designated on the notice if I have a question or complaint. To the extent permitted by law, I consent to the use
and disclosure of my information for the purposes described in the practice’s Notice of Privacy Practices.
______ (Patient initials) Release of Information. I hereby permit practice and the physicians or other health professionals
involved in the inpatient or outpatient care to release healthcare information for purposes of treatment, payment, or healthcare
______ Healthcare information regarding a prior admission(s) at other HCA affiliated facilities may be made available to
subsequent HCA-affiliated admitting facilities to coordinate Patient care or for case management purposes. Healthcare
information may be released to any person or entity liable for payment on the Patient’s behalf in order to verify coverage or
payment questions, or for any other purpose related to benefit payment. Healthcare information may also be released to my
employer’s designee when the services delivered are related to a claim under worker’s compensation.
______ If I am covered by Medicare or Medicaid, I authorize the release of healthcare information to the Social Security
Administration or its intermediaries or carriers for payment of a Medicare claim or to the appropriate state agency for payment of
a Medicaid claim. This information may include, without limitation, history and physical, emergency records, laboratory reports,
operative reports, physician progress notes, nurse’s notes, consultations, psychological and/or psychiatric reports, drug and
alcohol treatment and discharge summary.
______ Federal and state laws may permit this facility to participate in organizations with other healthcare providers, insurers,
and/or other health care industry participants and their subcontractors in order for these individuals and entities to share my
health information with one another to accomplish goals that may include but not be limited to: improving the accuracy and
increasing the availability of my health records; decreasing the time needed to access my information; aggregating and
comparing my information for quality improvement purposes; and such other purposes as may be permitted by law. I
understand that this facility may be a member of one or more such organizations. This consent specifically includes information
concerning psychological conditions, psychiatric conditions, intellectual disability conditions, genetic information, chemical
dependency conditions and/or infectious diseases including, but not limited to, blood borne diseases, such as HIV and AIDS.
Disclosures to Friends and/or Family Members
I give permission for my Protected Health Information to be disclosed for purposes of communicating results, findings and care
decisions to the family members and others listed below:
Contact Number
Consent to Email or Text Usage for Appointment Reminders and Other Healthcare Communications:
Patients in our practice may be contacted via email and/or text messaging to remind you of an appointment, to obtain
feedback on your experience with our healthcare team, and to provide general health reminders/information.
If at any time I provide an email or text address at which I may be contacted, I consent to receiving appointment reminders and
other healthcare communications/information at that email or text address from the Practice.
______ (Patient initials) I consent to receive text messages from the practice at my cell phone and any number forwarded or
transferred to that number or emails to receive communication as stated above. I understand that this request to receive emails
and text messages will apply to all future appointment reminders/feedback/health information unless I request a change in
writing (see revocation section below).
The cell phone number that I authorize to receive text messages for appointment reminders, feedback, and general health
reminders/information is______________________________. 000 - 0000.
The email that I authorize to receive email messages for appointment reminders and general health
reminders/feedback/information is______________________________.
The practice does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan
(contact your carrier for pricing plans and details).
I hereby revoke my request for future communications via email and/or text.
__I hereby revoke my request to receive any future appointment reminders, feedback, and general health via
text messages.
__ I hereby revoke my request to receive any future appointment reminders, feedback, and general health via
NOTE: This revocation only applies to communications from this Practice.
Patient Name: ________________________________________________________
Patient/Patient Representative Signature: _______________________________________________
Consent for Photographing or Other Recording for Security and/or Health Care Operations
____ (Patient Initials) I consent to photographs, videotapes, digital or audio recordings, and/or images of me being recorded for
security purposes and/or the practice’s health care operations purposes (e.g., quality improvement activities). I understand that
the facility retains the ownership rights to the images and/or recordings. I will be allowed to request access to or copies of the
images and/or recordings when technologically feasible unless otherwise prohibited by law. I understand that these images
and/or recordings will be securely stored and protected. Images and/or recordings in which I am identified will not be released
and/or used without a specific written authorization from me or my legal representative unless it is for treatment, payment or
health care operations purposes or otherwise permitted or required by law.
Prescription Order Pick-up.
There may be times when you need a friend or family member to pick-up a prescription order (script) from your physician’s
office. In order for us to release a prescription to your family member or friend, we will need to have a record of their name.
Prior to release of the script, your designee will need to present valid picture identification and sign for the prescription.
____ (Patient initials) I wish to designate the following family member / friend to pick up an order on my behalf:
Name: _________________________________________________ Date: ___________________
Name: _________________________________________________ Date: ___________________
____ (Patient initials) I do not want to designate anyone to pick-up my prescription order.
Patient Signature _________________________________ Date __________________________