Consent to Collect Use, and Disclose Personal Health Information

Please read this carefully before you sign the consent form with our practitioners 

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I (or the substitute decision-maker listed below) have read the following consent information for the practitioner to collect, use and disclose my personal health information for the purpose of providing treatment needed.

 

I understand that the personal health information that may be collected, used or disclosed by the Clinic may include the following, among other things: • my birth date and contact information • my health history and family health history • my health status • the health care I receive (including identifying my health care provider(s)) • my health number • the identification of my substitute decision-maker, if any • insurance or billing information relating to health care.

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I understand that my personal health information may be collected, used or disclosed for the following reasons: • To provide me with treatment needed • To obtain payment for services provided • To assist insurance companies with insurance claims verification • To seek advice for potential treatment options • To provide or arrange health care in cases of emergencies • To fulfill any obligations as mandated by law, there may be situations in which practitioners will have to collect, use or disclose personal health information without my consent, but that they will only do this if permitted by law.

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I understand that my personal health information is available to me for my review except in limited circumstances as permitted by law. I also understand that I can ask to have my personal health information corrected if I believe there is a mistake in the records, with some exceptions.

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I understand that I am not required to sign this form and that I can withdraw my consent at any time by contacting the practitioner, but it may directly affect the services I can receive. My personal health information may still be collected, used or disclosed if permitted by law.

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