Barbara A. White, MSN, CRNP
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CONSENT TO USE AND DISCLOSE
PROTECTED HEALTH INFORMATION (PHI)
USE AND DISCLOSURE OF YOUR PHI:
Your protected health information (PHI) will be used only by Barbara A. White, MSN, CRNP, or disclosed to others for the purposes of treatment, obtaining payment, or supporting the day to day health care operations of the practice.
REQUESTING A RESTRICTION ON THE USE OR DISCLOSURE OF YOUR PHI:
You may request a restriction on the use or disclosure of your PHI. If Barbara A. White, MSN, CRNP, agrees to your request, the restriction will be binding to the practice. Use of disclosure of PHI in violation of an agreed upon restriction will be a violation of the federal privacy standards.
REVOCATION OF CONSENT:
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.
NOTICE OF PRIVACY PRACTICES:
You have received the Notice of Privacy Practices with a complete description of how your PHI may be used or disclosed.
RESERVATION OF RIGHT TO CHANGE PRIVACY PRACTICES:
Barbara A. White, MSN, CRNP, reserves the right to modify the privacy practices outlined in the notice.
I have received a copy of the Notice of Privacy Practices and have reviewed this consent form and give my permission to Barbara A. White, MSN, CRNP, to use and disclose my health information in accordance with it.
Name of Patient: ______
Signature of Patient: ______
Date: ______Social Security #: ______
Name of Patient’s Representative: ______
Signature of Patient’s Representative: ______
Relationship of Representative to Patient: ______
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13 C Street, Suite G, Laurel, MD 20707 Phone: 301-617-2767
www.barbarawhitecrnp.com Fax: 301-617-3971
Pager: 301-441-0925