THIS PATIENT CONSENT FORM IS FOR THE USE AND DISCLOSURE OF HEALTH
INFORMATION, FOR TREATMENT, PAYMENT AND/OR HEALTHCARE OPERATIONS.
I understand that as part of my health care, Dr.Chandrakant Mehta, Dr.Amal Mehta, Dr.Dharmarajan
Ramaswamy, Lisa Garcia, FNP, Southland Arthritis & Osteoporosis Medical Center, C.V.Mehta MD
Medical Corporation and their affiliates originates and maintains paper and/or electronic medical
records describing my health history, symptoms, examination, test results, diagnosis, treatment, and
any plans for the future care of treatment. I understand that this 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 the services billed were actually provided.
- A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.
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:
- The right to review the notice prior to signing the consent,
- The right to object to the use of my health information for directory purposes
- The right to request restrictions as to how my health information may be used or disclosed to carry
out treatment, payment, or health care options.
I understand that Dr.Chandrakant Mehta, Dr.Amal Mehta, Dr.Dharmarajan Ramaswamy, Lisa
Garcia, FNP, Southland Arthritis & Osteoporosis Medical Center, C.V.Mehta MD Medical
Corporation and their affiliates are not required to agree to the restrictions requested. I understand
that they may revoke this consent in writing. I also understand that by refusing to sign this consent,
this organization may refuse to treat me as permitted by section 164:506 of the code of Federal
Regulations. I understand that Dr.Chandrakant Mehta, Dr.Amal Mehta, Dr.Dharmarajan
Ramaswamy, Lisa Garcia, FNP, Southland Arthritis & Osteoporosis Medical Center, C.V.Mehta MD
Medical Corporation and their affiliates reserves the right to change this notice and practices in
accordance with section 164:520 of the code of Federal Regulations. Should this organization
change the notice, they will send me a copy of any revised notice to the address I have provided
(whether by U.S. mail or by Email).
I understand that as part of this organization’s treatment, payment, or health care options, 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, answering machine, or a
family member. I fully understand and accept the terms of this consent.