Consent for Disclosure

Client/Patient Consent for Use and Disclosure of Protected Health Information


Client/Patient Consent for Use *
Client/Patient Consent for Use
I hereby give my consent for Boston NAPS, LLC 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 Boston NAPS describes such uses and disclosures more completely.) I have the right to review the Notice of Privacy Practices prior to signing this consent. Boston NAPS, LLC 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 Boston NAPS, LLC, 724 East 2nd Street, Unit 1, Boston, MA 02127, or by emailing bostonnaps@gmail.com. With this consent, Boston NAPS, LLC 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, Boston NAPS, LLC 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 as long as they are marked “Personal and Confidential.” With this consent, Boston NAPS, LLC 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 Boston NAPS, LLC 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. By signing this form, I am consenting to allow Boston NAPS, LLC to use and disclose my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Boston NAPS, LLC may decline to provide treatment to me.
ELECTRONIC SIGNATURE for Client
Date *
Date
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance. *
Child's Name
Child's Name
ELECTRONIC SIGNATURE for Legal Guardian (if applicable)
Date
Date
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.