HIPAA
Consent to the Use and Disclosure of Health Information
For Treatment, Payment, or Healthcare Operations
I understand that as part of my health and medical care, Shawnee Medical Center Clinic originates and maintains medical and health records describing my health history, symptoms, examinations and test results, diagnoses, treatment, and any plans for future care or treatment. I further understand that this information serves as:
- a basis for planning my care and treatment
- a means of communication among the health professionals who contribute to my care
- a source of information for applying my diagnosis and treatment information to my bill
- a means for a third-party payer to verify that services were billed as actually provided
- and a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.
I further understand and agree that this agreement to release information shall apply to all information accumulated up to this date and to any information acquired in the future. This agreement to release future information shall remain in force until such time as I shall revoke it in writing.
I understand and have been provided with a PATIENT PRIVACY NOTICE that provides a more complete description of information uses and disclosures. I understand that I have the right to review the PATIENT PRIVACY NOTICE prior to signing this consent. I understand that the Shawnee Medical Center Clinic reserves the right to change their notice and practices, but will present me with the new revised copy at my next scheduled appointment following the changes. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that Shawnee Medical Center Clinic is not required to agree to the restrictions requested. I understand that I must revoke this consent in writing, except to the extent the organization has already taken action in reliance thereon.
By Oklahoma law we are required to notify you ..... that the information authorized for release may include records which may indicate the presence of a communicable or venereal disease which may include, but are or limited to, diseases such as hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as Acquired Immune Deficiency Syndrome (AIDS). SMCC 24-103
REVISED 07/06
