NYC-Metro Physician Services, PC

VERBAL DISCLOSURE OF PROTECTED HEALTH INFORMATION

Patient Name________________________________________________________________________________________________ 	

Date of Birth_____________________________________________Medical Record Number________________________________  	

HIPAA (The Health Insurance Portability and Accountability Act) gives you the right to request that we communicate financial and or medical information to you in confidence by a particular method.   In order to protect the privacy and confidentiality of your information, please complete the following.  This form will tell us how you wish to be contacted and with whom we may discuss your healthcare, insurance and billing questions.

I give permission for (check all that applies):

•	Correspondence from NYC-Metro Physician Services may be sent to my attention in a sealed envelope marked “CONFIDENTIAL.”

•	Confidential messages (such as appointment reminders, normal test results) may be left on my home answering machine or voicemail.			                                                                         HOME PHONE #_________________________  	

•	Confidential messages (such as appointment reminders, normal test results) may be left on my work voicemail.	                                                                      
       WORK PHONE # _________________________ 	

•	Confidential messages (such as appointment reminders, normal test results) may be left on my cell phone voicemail.	                                                                    
 						                                         CELL PHONE # _________________________  	

I hereby authorize NYC-Metro Physician Services to release PHI to the person(s) listed below: (i.e. spouse, family members, friends, caregiver, etc.).

__________________________________________________________________________________________________________
Name				Phone Number				Relationship to Patient

__________________________________________________________________________________________________________
Name				Phone Number				Relationship to Patient

__________________________________________________________________________________________________________
Name				Phone Number				Relationship to Patient

I understand that I may revoke this authorization at any time by notifying Creekside Medical in writing and the revocation will be effective on the date noted, except to the extent action has already been taken in reliance upon it.

I understand that information used or disclosed pursuant to this authorization may be subject to re- disclosure by the recipient and may no longer be protected by federal or state privacy regulations.

__________________________________________________________________________________________________________
Patient or legally authorized individual signature					Date			Time

__________________________________________________________________________________________________________
Printed name if signed on behalf of the patient                  Relationship (parent, legal guardian, personal representative)