Consent to Use and Disclosure of Protected Health Information (PHI)
Your PHI will be used by HealthWorks Chiropractic and/or Alvin Health and may be disclosed to others for the purposes of treatment, obtaining payment or supporting the day-to-day operations of this office.
You should review the Notice of Privacy Practices for a more complete description of how your PHI may be used or disclosed. It describes your rights as they concern the, limited use of health information, including your demographic information, collected from you and created or received by this office.
You may review the Notice prior to signing this consent. You may request a copy of the Notice at the Front Desk. You may request a restriction on the use of disclosure of your PHI, however, we may or may not agree to restrict the use or disclosure of your PHI.
If we agree to your request, the restriction will be binding with this office. Use or disclosure of Protected information in violation of an agreed upon restriction will be violation of the federal privacy standards.
You may revoke this consent to the use and disclosure of your PHI. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.
Please note that HealthWorks and Alvin Health reserve the right to modify the privacy practices outlined in the Notice.
Authorization for Use and Disclosure of PHI
The Information to Be Used or Disclosed covered by this authorization includes:
· We may use your email to notify you of announcements, health tips and appointment reminders
· We may use your cellphone number to send you text messages for your appointments and events
· We may use your home address to send you a yearly birthday card
Persons authorized to Use or Disclose Information
Information will be used or disclosed by the staff, contractors and agents of HealthWorks Chiropractic or Alvin Health.
Expiration Date of Authorization / Right to Terminate
This authorization is effective for a five-year period that renews automatically unless revoked or terminated by patient or patient’s personal representative in writing.
Potential for Re-Disclosure
Information that is disclosed under this authorization may be disclosed again by the person or organization to which it is sent. The privacy of this information may not be protected under the federal privacy regulations. The use or disclosure requested under this authorization will not result in direct or indirect remuneration to this office.