M.L.F. Knuckles, M.D., P.S.C.1101 E. Master St. 519 Hampton Way, Ste. 4
DERMATOLOGYCorbin, KY40701Richmond, KY40475
Phone: 606-528-2881Phone: 859-623-0064
Fax: 606-528-0293Fax: 859-623-0804
HIPPA: Consent for the Use or Disclosure of Protected Health Information
As required by the Health Insurance Portability and Accountability Act of 1996 this practice may not use your personal health information for the purposes of treatment, payment or health care operations. The specific uses and disclosures that we intend to make are described in our Notice of Information Practices. You have the right to review the Notice of Information Practices prior to signing this consent form. You are consenting to allow this practice to use and disclosure your protected health information to carry out TPO: Treatment means the provision, coordination or management of healthcare and related services by one or more healthcare providers or the referral of a patient for healthcare from one provider to another. Payment means the activities conducted by the practice to obtain reimbursement for healthcare services. This includes, among others, billing claims management, collection activities, verification of insurance coverage, and pre-certification of services. Healthcare Operations means activities related to this practice’s business and clinical management and administrative duties.
CONSENT SECTION:
I hereby consent to the use and disclosure of my personal health information for the purposes of treatment, payment and health care operations. My signature below indicates that I have been given an opportunity to read the Notice of Information Practices and to have any questions answered before signing.
I understand that I may request restrictions on the uses and disclosures of my health information at any time by completing and signing the restriction request form. I further understand that the practice is required to accept my restriction/s request. (restriction form available at front desk)
I understand that I may revoke this consent at any time by signing the revocation section of this form and returning it to the practice. I further understand that any such revocation does not apply to the extent that persons authorized to use or disclose my health information have already acted in reliance on this consent. (revocation form available at the front desk)
In conjunction with these privacy practices you will need to provide us with the following information:
1. Name of person(s) we may speak to regarding your health (i.e. spouse, child, etc., including a phone number.)
Name: ______Relationship: ______Phone: ______
Name: ______Relationship: ______Phone: ______
2. May we leave a message regarding your health or an appointment/change on your answering machine? YES:__ NO:__
______
Signature of Patient and/or Legal GuardianDate