Consent for Treatment at Fairlawn Family Practice
50 North Miller Road
Fairlawn, Ohio 44333
Consent for Purpose of Treatment, Payment and Healthcare Operations
I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Fairlawn Family Practice is not required to agree to the restrictions that I may request. However, if Fairlawn Family Practice agrees to a restriction that I request, the restriction is binding on Fairlawn Family Practice and its healthcare providers.
I have the right to revoke this consent, in writing, at any time, except to the extent that Fairlawn Family Practice has taken action in reliance on this consent.
My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearninghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.
I understand I have a right to review Fairlawn Family Practice’s Notice of Privacy Practices prior to signing this document. The Fairlawn Family Practice’s Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of the Fairlawn Family Practice. The Notice of Privacy Practices for Fairlawn Family Practice is also provided in the waiting area and is available upon request. This Notice of Privacy Practices also describes my rights and Fairlawn Family Practice’s duties with respect to my protected health information.
Fairlawn Family Practice reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be available for pickup, or asking for one at the time of my next appointment.
Name of Patient/Representative
Signature of Patient/Representative
Description of Representative’s Authority