CONSENT FORM

For Use and Disclosure of Protected Health Information (PHI)

 

                                                           06-28-2006

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

 You have the right to review our Notice of Privacy Practices and we encourage you to do so prior to signing this acknowledgement.  It provides more detail on how we may use and disclose your information.  The Notice of Privacy Practices may change.  A current copy may be requested when you are being seen as a patient, by contacting our facility at 814 849-2312, or by visiting our website at www.brookvillehospital.org.

 We may use and disclose health information, without your authorization, for the following purposes: 

 

“For Treatment:  We may use or disclose your health information to a physician or other healthcare provider to provide you with medical treatment and services.  For example, we may need to arrange for medical services for you for continuity of care purposes.

 

“For Payment:  We may use or disclose your health information in our payment for the services that have been provided to you.  For example, in order for us to make payment to your health care provides, we will need to review information from your health care provider.

 

“For Health Care Operations:  We may use and disclose your health information for our own purpose.  Some of the ways in which we use your health information include monitoring quality of care, checking compliance with laws and other legal obligations, education, health care  contracting, legal services; business planning and development, business management and administration, and underwriting and other insurance activities. 

 You may request that we restrict how we use and disclose your protected health information for the purpose of treatment, payment, and health care operations.  If you are requesting a restriction, please initial __________ (patient's initials) indicating that additional information will be placed on a separately attached page.  If we grant your request, we are bound by the terms of that agreement. 

 I AUTHORIZE BROOKVILLE HOSPITAL TO USE AND DISCLOSE MY PROTECTED HEALTH INFORMATION FOR THE PURPOSE OF TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS. 

 

________________________________________________________________________

Signature of Patient or Surrogate Decision Maker             Relationship                    Date

 

________________________________________________________________________

Patient's Printed Name                                       Medical Record Number 

                     

          Failure to Obtain Authorization

___   Indirect Treatment Relationship Exists

___   Emergency Treatment

___   Treatment Required by Law                  

___   Substantial Barriers in Communication

___   Refusal to Sign      

___   Other ___________________________

 

Brookville Hospital Signature #1 _____________________Date_________________

                                 Signature #2 _____________________Date_________________

 

 

Form # ADM-30MR 04/06

Brookville Hospital, Brookville, PA  15825