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CONSENT TO USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION *
Use and disclosure of your protected health information will be used by North Georgia Pregnancy Services Center Dahlonega/Dawsonville or disclosed to others for the purposes of treatment or supporting the day-to-day health care operations of the organization.
Notice of Privacy Practices
You should review the Notice of Privacy Practices for a more complete description of how your protected health information may be used or disclosed. You may review the notice prior to signing this consent.
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Requesting a restriction on the use or disclosure of your information
You may request a restriction on the use or disclosure of your protected health information.
North Georgia Pregnancy Services Center Dahlonega/Dawsonville may or may not agree to restrict the use on disclosure of your protected health information.
If North Georgia Pregnancy Services Center Dahlonega/Dawsonville agrees to your request, the restriction will be binding on the organization. Use or disclosure of protected health information in violation of an agreed upon restriction will be a violation of the federal privacy standards.
Revocation of consent
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.
Reservation of right to change privacy practices
North Georgia Pregnancy Services Center Dahlonega/Dawsonville reserves the right to modify the privacy practices outlined in the notice.
Signature:
I have reviewed this consent form and give my permission to North Georgia Pregnancy Services Center Dahlonega/Dawsonville to use and disclose my health information in accordance with the Notice of Privacy Practices.
Date: ________________
Printed Name of Patient: _________________________________________________
Signature of Patient: ___________________________________________________________
Signature of Patient Representative: ______________________________________________
Relationship of Patient Representative to Patient: ____________________________________
Internal Use Only
If patient or patient's representative refuses to sign acknowledgment, please document date and time notice was presented to patient and sign below.
Presented on (Date): _______________ Time: _______________ (circle) a.m. p.m.
By (Name and Title): ____________________________________________________________
*(to be filed in patient's medical record)