Patient Consent for Use and Disclosure of PHI

We take the privacy of your medical records seriously and adhere to HIPAA standards.

All patients must sign the following disclosure form before being seen:

SOUTHWEST INTERNAL MEDICINE
PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

With my consent Southwest Internal Medicine may use and disclose protected  health information (PHI) about me to carry out treatment, payment, and healthcare operations (TPO). Please refer to Southwest lnternal Medicine’s Notice of Privacy Practices for a more complete description of such disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Southwest Internal Medicine 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 Southwest Internal Medicine Privacy Officer at 736 S 900 E Suite 104, St. George, UT 84790.

With my consent, Southwest Internal Medicine may call my home or other designated location and leave a message on voice mail in person in reference to any times 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.

With my consent, Southwest Internal Medicine 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.

With my consent, Southwest Internal Medicine may e-mail to my home or other designated location any times that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Southwest Internal Medicine restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to Southwest Internal Medicine’s use and disclosure of my PHI to carry out TPO.

I may revoke my consent in writing extent to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Southwest Internal Medicine may decline to provide treatment to me.