ORAL AND MAXILLOFACIAL SURGERY / CENTRAL NEW JERSEY
CONSENT FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION
SECTION A: PATIENT GIVING CONSENT
Name: __________________________________
Address: ________________________________
Telephone: Home - _______________ Work - _______________ E-mail - _________________________________
Social Security Number: _________________________________
SECTION B: TO THE PATIENT-- PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.
PURPOSE OF CONSENT: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.
NOTICE OF PRIVACY PRACTICES: You have the right to read our notice of privacy practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and other important matters about your protected health information. A copy of our notice accompanies this consent. We encourage you to read it carefully and completely before signing the consent.
We reserve the right to change our privacy practices as described in our notice of privacy practices. If we change our privacy practices, we will issue a revised notice of privacy practice, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our notice of privacy practices, including any revisions of your notice, at any time by contacting:
CONTACT OUR PRACTICE: Telephone: 609-587-2900 Fax: 609-587-1749
Address: 2303 Whitehorse-Mercerville Rd. 63 Princeton-Hightstown Rd., Suite 2A
Mercerville, NJ 08619 Princeton Junction, NJ 08550
RIGHT TO REVOKE: You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this consent.
Patient Signature: ________________________________________________ Date: ________________
I, _________________________, have had full opportunity to read and consider the contents of this consent form and your notice of privacy practices. I understand that, by signing the consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.
Patient Signature: ________________________________________________ Date: ________________
If this consent is signed by a personal representative on behalf of the patient, complete the following.
Personal Representative Name: __________________________________________________________
Relationship to Patient: ____________________________________________________________________
YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.
INCLUDE COMPLETED CONSENT IN THE PATIENT’S CHART.
REVOCATION OF CONSENT
I revoke my consent for your use and disclosure of my protected health information for treatment, payment activities and healthcare operations.
I understand that revocation of my consent will not affect any action you took in reliance on my consent before you received this written notice of revocation. I also understand that you may decline to treat or continue to treat me after I have revoked my consent.
Patient Signature: ____________________________________________________ Date: _____________________
I give my consent for OMSCNJ to contact me by calling my home or other designated location in order to leave a message (mechanically or with another person) or to speak to me directly regarding any matter which will help with the conduct of Treatment, Payment, and Healthcare Operations.
Further, I give my consent for the use of mail or e-mail to designate locations, including home, to assist OMSCNJ in carrying out the described activities of Treatment, Payment, and Healthcare Operations.
Additionally, I hereby allow access to my records by the following individuals:
1)____________________________________________________Relationship:______________________________
2)____________________________________________________Relationship:______________________________
____________________________________ ________________________
Patient Signature Date
____________________________________ ________________________
Signature of Legal Adult or Guardian Date
................
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