I, at this moment, give my consent for Priority Medical Group, LLC (the Practice) to use and disclose my protected health information (PHI) to perform treatment, payment, and health care operations (TPO).
With this consent, the Practice may call or email me at my home or other alternative location and leave a message by voice, email, or in person regarding any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and anything pertaining to my clinical care, including laboratory test results.
With this consent, the Practice may mail to my home or other alternative location any items that assist the practice in performing TPO, such as appointment reminder cards, patient statements, and anything about my clinical care, if they are marked “Personal and Confidential.”
By signing this form, I consent to using and disclosing my PHI to carry out TPO.
I may revoke my consent in writing, except to the extent that the Practice has already made disclosures with my prior consent. If I do not sign this consent or later revoke it, the Practice may decline to provide me with treatment.