I hereby give my consent to Dr. P. DeFrank to use and disclose protected health information (PHI)* about me to carryout treatment, payment and health care operations. (TPO).* (The Notice of Privacy Practices provided by Dr. P. DeFrank describes such uses and disclosures more completely).

I have the right to review the Notice of Privacy Practices prior to signing this consent. Dr. P. DeFrank reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to HCA Privacy Officer, 17194 Preston Road #222, Dallas, TX 75248, or you may call 972.267.3338.

With this consent, Dr. P. DeFrank may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO* such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.

With this consent, Dr. P. DeFrank may mail to my home or other alternative location any items that assist the practice in carrying out the TPO* such as appointment reminder cards and patient statements as long as they are marked "Personal and Confidential."

With this consent, Dr. P. DeFrank may email to my home or other alternative location any items that assist the practice in carrying out the TPO* such as appointment reminder cards and patient statements. I have the right to request that Dr. P. DeFrank restrict how it uses and discloses my PHI to carry out TPO. The practice is not required to agree to any requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to allow Dr. P. DeFrank to use and disclose my PHI* to carry out TPO*.

By signing this form, I am consenting to allow Dr. P. DeFrank to use and disclose my PHI* to North Texas Clinical Research, a covered entity, for possible protocol qualification.

I may remove my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do sign this consent, or later revoke it, Dr. P. DeFrank may decline to provide treatment to me.

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Signature of Patient or Legal Guardian

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Date

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Relationship to Patient

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PRINT Patient's Name

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Print Name of Legal Guardian, if applicable

*PHI: Protected Health Information
*TPO: Treatment, payment operations

Dr. Peter R. DeFrank - Dallas Foot Care Center

17194 Preston Road Suite 222 Dallas, TX 75248 Tel: 972.267.3338 Fax: 972.267.1815 VIEW MAP >>