AUTHORIZATION TO GIVE MEDICAL CARE - CONSENT TO TREATMENT I hereby voluntarily consent to outpatient care from the Primary Care Clinic at ClearPath Family Healthcare encompassing routine diagnostic procedures, examination, and medical treatment including (but not limited to) routine laboratory work and administration of medications as prescribed by the Providers. I further consent to the performance of those diagnostic procedures, examinations, and rendering of medical treatment by the Primary Care Clinic at ClearPath Family Healthcare medical Providers and staff, as is necessary in the medical staff's judgment. I understand that during the course of treatment, health care workers may be exposed to the patients' blood and/or body fluids increasing their risk of contracting Hepatitis B, Hepatitis C, and/or HIV. In the event an exposure occurs, I understand the need for testing for these diseasesandIagreeto such testing of myself to promote the health and welfare of the health care worker. I understand that this consent will be valid and remain in effect as long as I attend the clinic.
AUTHORIZATION TO RELEASE INFORMATION I hereby authorize the Primary Care Clinic at ClearPath Family Healthcare Center to release any information acquired in the course of my examination and treatment to any authorized agent for the purposes of healthcare, treatment, and payment. I authorize the release of medical information to my insurers as necessary for determination and payment of benefits; to healthcare providers involved in my care; to utilization review and professional standards review organizations, companies, and community resources that assist me with my healthcare needs.
NOTIFICATION OF PRIVACY I have received the ClearPath Family Healthcare Center Notice of Privacy Practices and Patient Rights.
AUTHORIZATION TO ACCESS RX HISTORY INFORMATION I hereby authorize the Primary Care Clinic at ClearPath Family Healthcare Medical Center to access historical prescription drug information.
ACKNOWLEDGEMENT OF PERSONAL PROPERTY I understand that the Primary Care Clinic shall not be liable for loss or damages of any personal property.
HEALTH INFORMATION EXCHANGES The Primary Care Clinic endorses, supports, and participates in electronic Health Information Exchange (HIE) as a means to improve the quality of your health and healthcare experience. HIE provides us with a way to securely and efficientlyshare patients' clinical information electronically with other physicians and health care providers that participate in the HIE network. Using HIE helps your health care providers to more effectively share information and provide you with better care. The HIE also enables emergency medical personnel and other providers who participate in the TIP program and who are treating you, to have immediate access to your medical data that may be critical for your care. Making your health information available to your health care providers through the HIE can also help reduce your costs by eliminating unnecessary duplication of tests and procedures. However, you may choose to opt-out of participation in the HEALTHCURRENT HIE, or cancel an opt-out choice, at any time by completing the appropriate form which will be provided upon your request. ClearPath Family Healthcare endorses, supports and participates in the Arizona Immunization and Information System (ASIIS ASIIS is a confidential, computerized, system that collects and consolidates vaccination data for Arizonans of all ages and provides tools for designing and sustaining effective immunization strategies to prevent disease and reduce healthcare costs. Information in the ASIIS system can be released only to individuals; individual's parent/legal guardian; individual's healthcare provider; a school or child care center where the individual is enrolled; health insurers if financially responsible for immunizations; healthcare organizations; Department of Health Care Policy and Financing for individuals enrolled in Medicaid. You may choose to opt-out of participation in the ASIIS system or cancel an opt-out choice. This notification must be in writing and may be presented at any time.