PATIENT PRIVACY CONSENT FORM                                                                          Back to Welcome

Effective Date:  November 1, 2005                    Please NOTE!  If you plan to print this document,
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THIS NOTICE DESCRIBES YOUR CONSENT TO OUR PRIVACY  POLICY  THAT WE USE IN  LONE STAR ORTHOPEDICS, P.A.     PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please contact Patti Greeson, Office Manager at (512) 353-8658.

WHO MUST FOLLOW THIS NOTICE?

All patients of Lone Star Orthopedics, P.A.

USE OF HEALTHCARE INFORMATION:

I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan and direct my treatment and follow-up among multiple healthcare providers who may be involved in that treatment directly or indirectly.

• Obtain payment from third party payers

• Conduct normal healthcare operations such as quality assessments and physician certifications.

YOU HAVE THE RIGHT TO INSPECT THE PRIVACY POLICY FOR LONE STAR ORTHOPEDICS:

I have been informed that the Privacy Policy for Lone Star Orthopedics contains a more complete and detailed description of the use and disclosure of my health information. I have been given the right to review such Privacy Policy prior to signing this form. I understand that this Privacy Policy is made available by contacting the staff of Lone Star Orthopedics, P.A. or by viewing on the website. I understand that this organization has the right to change its Privacy Policy from time to time and that I may contact this organization at any time to obtain a current copy of the Privacy Policy.

CONTACT FOR TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS:

With this consent, Lone Star Orthopedics, P.A. 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 treatment, payment, or healthcare operations, such as appointment reminders, insurance items, and any calls pertaining to my clinical care, including laboratory results among others.

With this consent, Lone Star Orthopedics, P.A. may mail to my home or other alternative location any items that assist the practice in carrying out  treatment, payment, or healthcare operations, such as appointment reminder cards, and patient statements.

OUR RIGHT OF REQUIRED CONSENT:

If you do not sign this Privacy Consent, we have the right to refuse you treatment unless a licensed healthcare professional has determined that you require emergency treatment or we are required by law to treat you. We are required to document any circumstances in which we do not obtain your consent, yet carry out treatment. We will offer you a copy of this documentation should you decide not to sign this Privacy Consent.

YOU HAVE THE RIGHT TO REQUEST RESTRICTIONS:

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand Lone Star Orthopedics, P.A.  is not required to agree to my requested restrictions, but if  Lone Star Orthopedics, P.A. does agree, then it is bound to abide by such restrictions. Such requests must be made in writing or by directly speaking to the office manager, Patti Greeson.

YOU HAVE THE RIGHT TO REVOKE CONSENT:

I understand that I may revoke this consent in writing at any time, except to the extent that Lone Star Orthopedics, P.A. may  have already taken action relying on this consent.

EFFECTIVE DATE:

Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect.

I HAVE READ AND UNDERSTAND THE ABOVE AND AGREE TO THE TERMS OF THIS PRIVACY CONSENT

Patient’s printed name_______________________________________________________________

Person responsible for consent (if not the patient)_________________________________________

Signature__________________________________________________________________________

Date___________________________

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