Nutritional Patient Privacy

AUTHORIZATION FOR USE AND DISLOSURE OF PROTECTED HEALTH INFORMATION

We are very concerned with protecting your privacy. While the law requires that you give us the disclosure, please understand that we have, and always will, respect the privacy of your health information.

There are several circumstances in which we may have to use or disclose your health information.

We may have to disclose your health information to another health care provider or a hospital if it is necessary to refer you to them for the diagnosis, assessment, or treatment of your health condition.
We may have to disclose your health information and billing records to another party if they are potentially responsible for the payment of your services.
We may need to use your health information within our practice for quality control or other operational purposes.

We have a more complete notice that provides a detailed description of how your health information may be used or disclosed. You have the right to review that notice before you sign this consent form (164.520). We reserve the right to change our privacy practices as described in that notice. If we make a change to our privacy practices, we will notify you in writing when you come in for treatment or by mail. Please feel free to call us at any time for a copy of our privacy notices.

I authorize Take 2 Healthcare to contact me with information related to my personal health needs and interests. The physician's office may use any phone number or email in my personal records to contact me. If contact is made by phone and I am unable to respond, a message may be left with my home answering machine or voicemail service. I may be contacted about the following:

Appointment reminders or schedule changes.
Information about alternative treatments, presentations or events.
Other health related information that may be of interest to me.
To contact me, I authorize Take 2 Healthcare to use and disclose the following information:
My Name, Address, Email and Phone Numbers.
The Name of my Physician and the Clinic where I was treated

NOTE: NO DIAGNOSIS OR TREATMENT INFORMATION WILL BE USED OR DISCLOSED.

Patient's First Name

Patient's Last Name

Date of Birth

Address of Patient

City

State

Zip Code

Phone

E-Mail

Take 2 Healthcare fully supports the protection of health information. Only the physician and office staff will use this information to contact you. While we retain the standard rights of disclosure as provided under HIPAA, this authorization allows us to access only the above authorized information for contact purposes.

This authorization will remain valid for ten (10) years from the date entered. You may revoke this authorization at any time or request to receive a copy of the protected health information to be used in writing to Take 2 Healthcare- 5777 Far Hills Avenue-Dayton,Ohio 45429. In this case,every effort will be made to discontinue future communications.

Date