New Horizons of the Genesee Valley,
Inc.
3 Episcopal Avenue
(585) 624 – 1350
Patient Consent Form
In April of 2003, new federal requirements regarding privacy
of information for health care patients took effect. H.I.P.A.A., the Health
Insurance Portability and Accountability Act requires
that all medical providers, insurance companies and others, put in place
controls to ensure that your personal medical
information is safe.
New Horizons of the Genesee
Valley, Inc. (here in referred to as NHGV) requests that each patient
sign this consent form which allows us to share protected health information
with physician offices, other medical personnel as well as your insurance
company. By signing this form, you
consent to our use and disclosure of protected health information about you for
treatment, payment and health care operations. You have the right to revoke
this consent, in writing, except where we have already made disclosures in
reliance on your prior consent.
Our Notice of Privacy
Practices provides information about how we may use and disclose protected
health information about you. You have the right to review our notice before
signing this consent.
Signature of Patient or
Representative: __________________________
Date _________________
Name of Patient or
Representative:
__________________________Date of Birth ______________
Authorization to Leave Messages
with Household Members/Answering Machine
From time to time it is
necessary for representatives of NHGV to leave messages for patients. The
purposes of these messages is to remind patients that they have an appointment,
to notify the patient that NHGV staff would like to discuss therapy progress,
or to ask a patient to call NHGV regarding an issue or concern. At no time will
a representative of NHGV discuss your medical circumstances or condition
without your consent. The purpose of this consent is to leave messages with
members of your household or on your answering machine/voice mail.
You have the right to revoke
this consent, in writing, except where we have already made disclosures in
reliance on your prior consent.
Patient Name:___________________________________________
Patient Signature:____________________________________
Date:_______________________