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New Patient Form 3 PHI Consent

Patient Consent For Use and Disclosure of Protected Health Information (PHI)

For the purpose of the following consent, Galesburg Dermatology Center will include all satellite offices, each owned and operated by Dr Sam Fayman.

With my consent, Galesburg Dermatology Center may use and disclose Protected Health Information(PHI) about me to carry out treatment, payment and healthcare operations(TPO). Please refer to Galesburg Dermatology Center's Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent

Galesburg Dermatology Center reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to:

Galesburg Dermatology Center. 201 N Prairie St Galesburg, Il 6140 They may also be viewed or downloaded from our website www.galesburgdermatology.com

With my consent, Galesburg Dermatology Center may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others.

List all that apply including spouse and children if applicable. If self only, write self.

With my consent Galesburg Dermatology Center may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements.

I have the right ti request that Galesburg Dermatology Center restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my my requested restrictions, but if it does, it is bound by this agreement.

By checking the agreement box, I am consenting to Galesburg Dermatologys use and disclosure of my PHI to carry out TPO

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not agree to this consent, Galesburg Dermatology nay decline to provide treatment to me.

required for all minor patients
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