PHI
• I hereby give my consent for Wholesome Health, LLC, to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO).
• The Notice of Privacy Practices provided by Wholesome Health, LLC, describes such uses and disclosures more completely
I have the right to review the Notice of Privacy Practices prior to signing this consent. Wholesome Health, LLC, reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Wholesome Health, LLC.
With this consent, Wholesome Health, LLC, 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 TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among other.
With this consent, Wholesome Health, LLC, may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient health records.
With this consent, Wholesome Health, LLC, may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Wholesome Health, LLC, restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to allow Wholesome Health, LLC, to sue and disclose my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.
If I do not sign this consent, or later revoke it, Wholesome Health, LLC, may decline to provide treatment me.
