Privacy Practice Form

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ACKNOWLEDGEMENT OF PRIVACY PRACTICE NOTICE

AND DESIGNATION OF DISCLOSURE

 

I.             Acknowledgement of Privacy Practice Notice

 

I have received a copy of the Heart Specialists Group’s Notice of Privacy Practices.

I hereby consent to the use or disclosure of my protected health information by, or on behalf of,

The Heart Specialists Group, LLC for purposes of treatment, payment or healthcare operations.

I understand that my protected health information may be used for such purposes without my written authorization.

 

____________________________                      _________________

          Print Patient’s Name                                                 Date of Birth

 

______________________________________              _________________

     Signature of Patient/Parent/Guardian                                           Date

 

 

  • Check here if you do not wish voice messages to be left on your answering

machine or voicemail.

                       Daytime phone number:______________________

 

II.      Designation of Certain Relatives, Close Friends and Other Caregivers

 

I agree that The Heart Specialists Group, LLC  may disclose certain documents

regarding my health information to a family member, close personal friend or other caregiver

because such a person is involved with my health care.

 

I designate the person(s) listed below as individual(s) involved with my health care provided by

The Heart Specialists Group for the purpose of making the disclosures described above. I understand that I am not

required to list anyone. I also understand that I may change this list at any time by submitting a

written request to The Heart Specialists Group.

 

Print Name:___________________ Relationship:_______________Date of Birth:_______

 

Print Name:___________________ Relationship:_______________Date of Birth:_______

 

Print Name:___________________ Relationship:_______________Date of Birth:_______

 

_________________________________                                 ________________

Signature of Patient/Parent/Guardian                                                   Date