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 Signature:____________________________________ Date:_______________________