Acknowledgement for Consent to Use and Disclosure of Protected Health Information (PHI)
By submitting this form, you are sending data over the internet to a secure third party database, used by SpinalWorks. While we follow the law regarding PHI, there is always a slight chance that nefarious forces make hack their way into any database system. You acknowledge these risks and agree to accept them in exchange for the convenience of using our online forms. In case you do not agree, please download the offline PDF forms of this New Patient Application to download from this link, print and bring into our office as a hard copy.
Your Protected Health Information will be used by SpinalWorks and may be disclosed to others for the purposes of treatment obtaining payment or supporting the day-to-day health care operations of this office.
You should review the Notice of Privacy Practices for a more complete description of how your Protected Health information may be used or disclosed. it describes your rights as they concern the, limited use of health information, including your demographic information, collected from you and created or received by this office.
You may review the Notice prior to signing this consent. You may request a copy of the Notice at the Front Desk.
You may request a restriction on the use of disclosure of your Protected Health Information, however, we may or may not agree to restrict the use or disclosure of your Protected Health Information.
If we agree to your request, the restriction will be binding with this office. Use or disclosure of Protected information in violation of an agreed upon restriction will be violation of the federal privacy standards.
You may revoke this consent to the use and disclosure of your Protected Health Information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.
Please note that SpinalWorks reserves the right to modify the privacy practices outlined in the Notice.
I have reviewed this consent from and give my permission to this office to use and disclose my health information in accordance with it.
Authorization for Use and Disclosure of Protected Health Information
The Information to Be Used or Disclosed covered by this authorization includes:
- We may use your email address to notify you of clinic announcements, health tips and appointment reminders
- We may use your cell phone number to send you text messages related to your appointments and clinic events
- We may use your home address to send you a yearly birthday card
Persons authorized to Use or Disclose Information
Information listed above will be used or disclosed by the staff, contractors and agents of SpinalWorks.
Expiration Date of Authorization / Right to Terminate
This authorization is effective for a five-year period that renews automatically unless revoked or terminated by patient or patient’s personal representative. You may revoke or terminate this authorization by submitting a written revocation to this office and contact privacy Officer.
Potential for Re-Disclosure
Information that is disclosed under this authorization may be disclosed again by the person or organization to which it is sent. The privacy of this information may not be protected under the federal privacy regulations.
The use or disclosure requested under this authorization will not result in direct or indirect remuneration to this office.
Your Agreement
I have read and understand the policies as noted above. I have read the above and hereby agree & authorize the release & use of my protected health information (PHI) as described above. I understand this office will not condition my treatment or payment on whether I provide authorization for the requested use or disclosure.