ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

and

PARENT CONSENT FORM

 

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

 

 

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 PRINT IT, SIGN IT, AND 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.

 

 

You have completed all the registration materials

and may return to the HOME PAGE

 

 

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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: _________________