NORMAN PARATHYROID CLINIC
3238 Cove Bend Drive
Tampa, FL 33613
Phone: 813.972.0000 Fax: 813.972.0077
Consent for Purposes of Treatment, Payment and Healthcare Operations
I consent to the use or disclosure of my protected health information by the Norman Parathyroid Clinic / Norman Endocrine Surgery Clinic for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Norman Parathyroid Clinic. I understand that diagnosis or treatment of me by James Norman MD and/or Douglas Politz, MD may be conditioned upon my consent as evidenced by my signature on this document, or by my electronic acknowledgment that I have read and understand it. I understand that any information gathered by the Norman Parathyroid Clinic will be done so only when I allow it and have consented to it, understanding that secure web servers and accepted encryption technology will be used to collect this information so that it is protected and not available to the public. No information will be gathered from me at any time unless I purposefully agree to it and actively engage in the process.
I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. The Norman Parathyroid Clinic is not required to agree to the restrictions that I may request. However, if the Norman Parathyroid Clinic agrees to a restriction that I request, the restriction is binding on the Norman Parathyroid Clinic.
I have the right to revoke this consent, in writing, at any time, except to the extent that James Norman, MD, Douglas Politz, MD, or The Norman Parathyroid Clinic has taken action in reliance on this consent.
My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.
I understand I have a right to review the Norman Parathyroid Clinic's Notice of Privacy Practices prior to signing this document. The Norman Parathyroid Clinic's Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of the Norman Parathyroid Clinic's. The Notice of Privacy Practices for the Norman Parathyroid Clinic is also provided at their principle office located at 3238 Cove Bend Drive Tampa, FL 33613; and on the Norman Parathyroid Clinic's website at www.parathyroid.com/Privacy Statement.htm. This Notice of Privacy Practices also describes my rights and the Norman Parathyroid Clinic's duties with respect to my protected health information.
The Norman Parathyroid Clinic reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by accessing www.parathyroid.com, calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.
By accessing this page and checking the appropriate box on the Insurance Form and/or the Patient History Form within Parathyroid.com, I acknowledge that I have seen and agree to these privacy terms.
This form is required of all patients seeking medical treatment
from any healthcare provider under the Health Insurance Portability
and
Accountability Act of 1996 (HIPAA) as passed by Congress and being enforced
April, 2003.
This form is © 2001 American Medical Association and
2003-2008 Norman Endocrine Surgery Clinic/Norman Parathyroid Clinic
All Rights Reserved
Read full text of the Norman Endocrine Surgery Clinic's Notice of Privacy Practices