HIPAA ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
With my consent, Second opinion app may use and disclose protected health information (PHI) about me to carry out treatment recommendations, payment and healthcare operations (TPO). Please refer to the Second opinion app of Privacy Practices for a more complete description of such uses and disclosures. The practice provides this form to comply with the Health Information Portability and Accountability Act (HIPAA) of 1996.
I have the right to review the Notice of Privacy Practices prior to signing this consent. Second opinion app reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Second opinion app Privacy Officer.
With my consent, Second opinion app may call my home or other designated location and leave a message on voicemail or email in reference to any items that assist the Second opinion app in carrying out treatment, payment and healthcare operations, such as appointments, insurance items and any call pertaining to my clinical care, including laboratory results and others.
With my consent, Second opinion app may mail to my home or other designated location any items that assist the practice in carrying out treatment, payment and healthcare operations such as appointment reminder cards and patient statement s.
With my consent, Second opinion app may email to my home or other designated location any items that assist the practice in carrying out treatment, payment and healthcare operations such as appointment reminder cards and patient statements. I have the right to request that Second opinion app restrict how it uses or discloses my protected health information to carry out treatment, payment and healthcare operations.
However, the practice is not required to agree to my request restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to Second opinion app ’ s use and disclosure of my protected health information to carry out treatment, payment and healthcare operations.
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 l do not sign this consent, Second opinion app may decline to provide a diagnosis to me.