Norman Urology Associates

Acknowledgement and Consent Form


STANDARD AUTHORIZATION TO USE OR SHARE PROTECTED HEALTH INFORMATION (PHI)
Please complete, print and bring this form to your appointment.

Patient Information

Today’s Date [date todaydate date-format:mm/dd/yy] Date of Birth [date dob date-format:mm/dd/yy]
Patient Name
Physical Address
Mailing Address
Patient’s Address
State
Zip Code
Primary Phone*  Home Cell Work Secondary Phone*  Home Cell Work
 Messages for appointment reminders or medical information may be left on my primaryanswering machine. Messages for appointment reminders or medical information may be left on my secondary phone Also email me appointment reminders

Scope & Purpose for sharing Information

I understand protected health information is information that identifies me. The purpose of this authorization is to allow Norman Urology Associates, P.C. to share my protected health information.

Authorization & Information to be Shared

I authorize Norman Urology Associates, P.C. as set for the below, to share my protected health information for medical and personal reasons, in addition to those already permitted by law.

Persons/Organizations Authorized to Receive My Information:
Name Phone & Fax Relationship Purpose

*By supplying my home phone number, mobile phone number, email address, and any other personal contact information, I authorize my health care provider to employ a third-party automated outreach & messaging system to use my personal information, the name of my care provider, the time and place of my scheduled appointment(s), and other limited information, for the purpose of notifying me of a pending appointment, missed appointment, overdue wellness visit, or any other reasonable healthcare related communication. I also authorize my healthcare provider to disclose to third parties, who may intercept these messages, limited protected health information regarding healthcare events, unpaid balances, missed appointments, and to leave a reminder message on my voice mail or answering system if I am unavailable at the number provided by me.*

Information to be Shared.

Select all that apply

Entire Medical Record (includes all records except Psychotherapy Notes)
 Psychotherapy Notes (if checking this box, no other boxes may be checked)
 Mental Health Records Pathology Report History and Physical Operation Report(s) Progress Notes Consultation Report(s) Discharge Summary EKG Report(s) Laboratory Report(s) Radiology Report(s) Physician’s Orders Radiology Films Alcohol or Drug Abuse Records

Expiration & Revocation

This Authorization will Expire(Choose one):

 12 months from the date signed Until revoked

Right to Revoke

I understand I may change this authorization at any time by writing to the address listed at the bottom of this form. I understand I cannot restrict information that may have already been shared based on this authorization.

Acknowledgements & Signatures

Acknowledgements
  1. I understand this authorization is voluntary and will not affect my eligibility for benefits, treatment,enrollment,or payment of claims.
  2. I understand Norman Urology Associates P.C. is authorized to share my protected health information for the purpose of marketing (i.e.,notification of upcoming urology seminars).I understand Norman Urology Associates, P.C,may receive either direct or indirect compensation for sharing my information in this case unless I choose not to participate.
  3. I understand if the person/organization authorized to receive my protected health information is not a health plan or health care provider, privacy regulations may no longer protect the information.
  4. I understand I may inspect or obtain a copy of the protected health information shared under this authorization by sending a written request to the address listed at the bottom of the form.
  5. I understand Norman Urology Associates, P.C., as a member of Oklahoma Physician Health Exchange (OPHX), may utilize an electronic network to exchange my protected health Information with other providers unless I choose not to participate.
  6. I acknowledge in formation authorized for release may include records which may indicate the presence of a communicable or non-communicable disease.
Consent to Declaration

This document must be signed by the individual or the individual’s legal guardian/representative.
Patient’s Name (Note: By entering your name in this box, constitutes a signed document (you will be asked to sign in person at your appointment
Authorization

Norman Urology Associates, PC accepts denies conditionally the restrictions imposed on release of information as stated above.