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I hereby acknowledge that I have received a copy of
this office's Notice of Privacy Practices, and I acknowledge
that I have been given the right to review this document
prior to signing this consent. I understand that the
Pediatric Ear, Nose & Throat Associates has the right to
change its Notice of Privacy Practices from time to time,
and that I may contact the office at any time to obtain a
current copy of the Notice of Privacy Practices.
I understand that, under the Health Insurance Portability
and Accountability Act of 1996 (HIPAA), I have certain
rights to privacy regarding my child's and my family's
protected health information. I understand that this
information can and will be used to: conduct, plan, and
direct my child's treatment and follow up among multiple
healthcare providers who may be involved in that treatment
directly and indirectly; obtain payment from third-party
payers; conduct normal healthcare operations such as quality
assessments and physician certifications.
I understand that, in order to maintain communications with
me about my child's health status and treatment, staff
members from the Pediatric Ear, Nose & Throat Associates
may from time to time communicate with me via electronic
mail and/or conventional postal delivery by the United
States Postal Service. I understand that transmissions by
either channel may be subject to unauthorized and illegal
interception, and I hereby hold harmless the Pediatric Ear,
Nose & Throat Associates and its staff members,
individually and collectively, for any damage or liability
should such interception occur.
I understand that I may request in writing that the
Pediatric Ear, Nose & Throat Associates should restrict
how my private health information is used or disclosed to
carry out treatment, payment, or health care operations. I
also understand that the Pediatric Ear, Nose & Throat
Associates is not required to agree to my requested
restrictions, but, if agreement is verified in writing, then
the Pediatric Ear, Nose & Throat Associates are bound to
abide by such restrictions.
I understand that I may revoke this consent in writing at
any time, except to the extent that Pediatric Ear, Nose
& Throat Associates has already taken action relying on
this consent.
_____________________________________________
signature
_____________________________________________
printed name and relation to child
_____________________________________________
child's name
______________________
date
OFFICE
USE
ONLY>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
We attempted to obtain signed acknowledgement of receipt of
our Notice of Privacy Practices and a signed Parent Consent
Form, but these could not be obtained because:
o Parent(s)
refused to sign
o
Communication barriers prohibited obtaining the
acknowledgement and consent
o An
emergency situation prevented us from obtaining
acknowledgement and consent
o Other --
Specify:
Certified by: ____________________________ Date:
_________________
Thank
you for taking the time to read and sign this
form. By federal law, this consent form must be
a part of your child’s record. Please bring
it with you to your child's next visit or FAX it
to us at
860-232-2750.
We are looking forward to seeing you soon.
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© 2010 Howard G.
Smith MD
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