Patient Consent for Use and Disclosure of Protected Health Information
I hereby give my consent for Arrowhead Health to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by Arrowhead Health describes such uses and disclosures more completely.)
I have the right to review the Notice of Privacy Practices prior to signing this consent. Arrowhead Health 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:
Arrowhead Family Health Center, P.C. d.b.a. Redirect Health
16390 North 59th Avenue,
Glendale, AZ 85306
With this consent, Arrowhead Health 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, Arrowhead Health may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements.
With this consent, Arrowhead Health may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Arrowhead Health restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.