Patient Health Information Consent Form
The patient understands and agrees to allow Spinal Rehab and Healthcare, LLC to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow Spinal Rehab and Healthcare, LLC to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment.
Additionally, the patient acknowledges that Spinal Rehab and Healthcare, LLC utilizes Artificial Intelligence (AI) software to assist in generating accurate and efficient clinical documentation for health records. This technology is used solely to enhance the quality of care and ensure comprehensive documentation of patient encounters.
1. The patient has the right to examine and obtain a copy of his/her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions.
2. A patient's written consent need only be obtained one time for all subsequent care given to the patient in this office.
3. The patient may provide a written request to revoke consent at any time during care. This would not affect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented.
4. For your security and right to privacy, all staff have been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions known by this office to assure that your records are not readily available to those who do not need them.
5. Patients have the right to file a formal complaint with our privacy official about any possible violation of these policies and procedures.
6. If the patient refuses to sign this consent for the purpose of treatment, payment, and health care operations, the physicians have the right to refuse to give care.
I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures. I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures.
