I understand that under the Health Insurance Portability and Act of 1996, HIPPA, that as a patient I have certain rights to privacy regarding my protected health information, PHI. I understand that my PHI can and will be used for treatment, payment and health care operations. I have been offered and/or received a copy of the Privacy Notice which describes how my health information may be used or disclosed. I understand it is my responsibility to read carefully and ask any questions that I may have. The notice may change at any time. If PHI is needed in order to provide emergent treatment or transfer, permission is granted for the medical practice of Dailey Pediatrics and Family Medicine to use or disclose on my behalf to another healthcare provider or facility in an emergent situation. I have been educated that I also have the right to restrict the right to disclose my PHI. I understand that if I pay in full for services and treatments/items provided at the time of service/visit, I may restrict the disclosure of my PHI to a health plan for payment.
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By signing below, I hereby authorize Dailey Pediatrics and Family Medicine to disclose my PHI with the following family members, friends, caretakers, or other representatives. I may revoke this authorization via writing at any time.
