PATIENT CONSENT FOR USE OF
PROTECTED HEALTH INFORMATION (PHI)
PATIENT NAME: ___________________________________________
WITH MY CONSENT THE OFFICES OF HECTOR L. FRANCO, M.D. IN THE COURSE
OF CONDUCTING NORMAL OFFICE FUNCTIONS TO CARRY OUT TREATMENT,
PAYMENT OR HEALTHCARE OPERATIONS MAY:
1. GIVE PROTECTED HEALTH INFORMATION (PHI) TO THE FAMILY
MEMBERS I HAVE LISTED UPON THEIR REQUEST:
( ) WIFE/HUSBAND __________________________________(NAMES)
( ) PARENT __________________________________
( ) SON __________________________________
( ) DAUGHTER __________________________________
( ) OTHER __________________________________
2. ( ) MAY SEND APPOINTMENT REMINDERS TO MY HOME AS APPROPRIATE
3. ( ) MAY CALL MY HOME AND LEAVE A MESSAGE ON THE "ANSWERING
MACHINE" OR SIMILAR DEVICE IF I AM NOT HOME WITH INFORMATION
THAT MAY CONTAIN SOME OF MY PROTECTED HEALTH INFORMATION
SUCH AS BIOPSY RESULTS OR LAB RESULTS
4. ( ) MAY SEND MARKETING INFORMATION ABOUT NEW OR UPDATED
SERVICES OR PROCEDURES THAT THIS OFFICE MAY OFFER SUCH
AS A NEW COSMETIC SERVICE.
I MAY REVOKE MY CONSENT IN WRITING AT ANY TIME EXCEPT TO THE EXTENT
THAT THE OFFICE HAS ALREADY MADE DISCLOSURES UPON RELIANCE OF MY
PRIOR CONSENT. I HAVE A RIGHT TO REVIEW THE NOTICE OF PRIVACY PRACTICES
AVAILABLE ON THIS WEBSITE OR IN OFFICE BEFORE SIGNING.
__________________________________________ DATE:________________
SIGNATURE OF PATIENT OR LEGAL GUARDIAN
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