Digestive Care Consultants
23451 Madison Street, Suite 290, Torrance, CA 90505 (310) 375-1246 fax (310) 375-0590

Patient Consent Form (Must Be Completed and Returned By Patient Prior To Treatment)

To the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations I, ___________________________, (Account Number:___________________) understand that as part of my health care, Digestive Care Consultants originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

I understand that Digestive Care Consultants is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

I further understand that Digestive Care Consultants reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should Digestive Care Consultants change their notice, they will send a copy of any revised notice to the address Iíve provided (whether U.S. mail or, if I agree, email).

I understand that as part of this organizationís treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax.

Can confidential messages be left on your answering machine or voicemail? [ ] YES [ ] NO

Please list, if any, person(s) whom we may inform about your medical condition, diagnosis, and/or financial account:
Name: ________________________ Phone Number: _____________________________
Name: ________________________ Phone Number: _____________________________
Name: ________________________ Phone Number: _____________________________
I wish to have the following restrictions to the use or disclosure of my health information:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

I fully understand and [ ] accept [ ] decline the terms of this consent.

__________________________________________ ___________________________
Patientís Signature Date

FOR OFFICE USE ONLY
[ ] Consent received by ______________________________ on ______________________________
[ ] Consent refused by patient, and treatment refused as permitted.
[ ] Consent added to the patientís medical record on ______________________________