New Patient Registration Form

Patient Consent to the Use and Disclosure of Health Information

for Treatment, Payment, or Healthcare Operations

I, _______________________, understand that as part of my health care, Springfield Cardiology (Ash Medical Inc. / Taj Medical Inc.) originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:

  • A basis for planning my care and treatment,
  • A means of communication among the many health professionals who contribute to my care,
  • A source of information for applying my diagnosis and surgical information to my bill
  • A means by which a third-party payer can verify that services billed were actually provided, and
  • A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

I understand that I have the following rights and privileges:

  • The right to review the notice of information practices prior to signing this consent,
  • The right to object to the use of my health information for directory purposes, and
  • The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations

I understand that Springfield Cardiology is not required to agree to the restrictions requested.  I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon.  I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

I further understand that Springfield Cardiology reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations.  Should Springfield Cardiology., change their notice, they will provide you a revised copy upon your next scheduled visit at the office.

I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax.

By signing this form you acknowledge, understand, and accept the above information.


_________________________________                             _____________________________________

Patient’s Signature                                                       Date

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