TFCZ01 HIPAA Form

HIPAA ACNKNOWLEDGEMENT AND CONSENT

Patient Name*

First NameMiddle NameLast Name

Date of Birth*

Date

I give permission for reasonable and necessary medical examinations, testing and treatment to be performed at The Foot Clinic, by the physician. By signing below, I am indicating that: (1) I intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended. (2) I consent to treatment at The Foot Clinic or any other satellite location under the care of Dr. Davis. (Patient Initials)*

I have the right to discuss the treatment plan with the physician about the purpose, potential risks and benefits of any test ordered for myself/my child. If I have any concerns regarding any test or treatment recommend by the health care provider, I am encouraged to ask questions. I give consent for The Foot Clinic to leave test results, orders, referral information and appointment reminders on my voicemail if unable to reach me personally. (Patient Initials) *

Disclosure to family and/or friends:

I give permission for my Protected Health Information (PHI) to be disclosed for purposes of communicating results, findings and care decisions to the family member and others listed below.:

	Name	Relationship	Phone Number
1.
2.
3.
4.

Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature*

Name

First NameLast Name

Date

The consent will remain fully effective until it is revoked in writing.
You have the right at any time to discontinue services.