PATIENT CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION
FOR TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS
- I understand that as part of my health care, Black Hills Obstetrics and Gynecology originates, records,
and maintains health information about me describing my health history, symptoms, examination
and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that
this health information may be used or disclosed by Black Hills Obstetrics and Gynecology for treatment,
payment, and health care operations. For example, my health information serves as:
- A basis for planning my care and treatment;
- A means of communication 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 health care professionals.
- I acknowledge that I have been provided with Black Hills Obstetrics and Gynecology’s Notice of
Privacy Practices that provides a more complete description of information uses and disclosures. I
understand that I have the right to review the Notice of Privacy prior to signing this consent. I understand
that Black Hills Obstetrics and Gynecology reserves the right to change its Notice of Privacy Practices and
prior to implementation will mail a copy of any revised notice to the address I have provided.
- I understand that I have 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, and that Black Hills Obstetrics
and Gynecology is not required to agree to the restrictions requested but if it does, it is bound by such
- I understand that I may revoke this consent in writing, except to the extent that Black Hills Obstetrics
and Gynecology has already taken action in reliance thereon. This signed consent shall remain in force
until the undersigned patient gives written notification, stating otherwise.
- By signing this form, I consent to Black Hills Obstetrics and Gynecology’s use and disclosure of
my health information for treatment, payment, and health care operations.
- I understand that this release of medical information may contain information regarding drug or
alcohol abuse, mental health issues and/or HIV (AIDS) and STD (Sexually Transmitted Diseases)
Note, if restrictions are added, you will be considered self pay.
- I, the undersigned, hereby assign to the physician(s) associated with Black Hills Obstetrics &
Gynecology LLP. all payments for medical services rendered to myself or my Dependant.
Digital Signature: Type full name
Guardian or Legal Representative:
Type full name