New Patient Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Health Care Operations.

Patient Name: _______________________________________           Date of Birth: ______________________

                       (Please Print)

I understand that as part of my heath care, Shahzada, Green, Thomson, MD’s and Ziegler, APRN at South Central Kansas Clinic (SCKC) originate and maintain paper and/or electronic records describing my health history, symptoms, examinations and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:

·         A basis for planning my care and treatment

·         A means of communications among the many health professionals who contribute to my care

·         A source of information for applying my diagnosis and surgical information to my bill

·         A means by which a third-party payer can verify that services billed were actually provided, and

·         A tool for routine health care operations such as assessing quality and reviewing the competence of healthcare professionals.

I understand and have been provided with Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

·         The right to review the notice prior to signing this consent

·         The right to access to PHI and/or request to amend PHI

·         The right to confidential communications

·         The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations.

I understand that Shahzada, Green, Thomson, MD’s and Ziegler, APRN at SCKC are not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that he organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by the federal regulations.

I further understand that Shahzada, Green, Thomson, MD’s and Ziegler, APRN at SCKC reserves the right to change their privacy practices outlined in this notice. If there is material revision of this Notice a copy will be provided to me. At any time I may obtain a copy of this notice by requesting in person at the office.

I hereby consent to the use and disclosure by Shahzada, Green, Thomson, MD’s and Ziegler, APRN at SCKC, its force and its business associate of my protected health information for the purposed of treatment, payment and health care operation.

Acknowledgement of Receipt of Privacy Notice

I acknowledge that I have received a copy of Notice of Privacy Practices with the effective date of June 23rd,2014.



Signature of Patient/ Patient Representative                                                                                      Date





Relationship of Patient Representative to Patient