TFCZ01 HIPAA Form

HIPAA ACNKNOWLEDGEMENT AND CONSENT
Patient Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.:

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

Digital Signature Authorization:
Signature
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
The consent will remain fully effective until it is revoked in writing.
You have the right at any time to discontinue services.
Should be Empty: