The Cummings Foundation For Behavioral Health

AUTHORIZATION: I hereby consent to and authorize the treating physician, associated personnel, and any other consulting physician called in by the above, to assess or provide first aid and to render medical treatment and health care services to the patient named on this form. I further consent to and authorize procedures or services which may be deemed necessary by said designated or consulting physician. I have been given no guarantee and rely on none as to the result of any assessment, first aid, treatment, or examinations. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been made to me as to the results of any assessment, first aid, diagnostic, medical, surgical, or therapeutic treatments, procedures, or examinations.

DISCLAIMER: This product is being covered by the Cummings Foundation for Behavioral Health and that it is not your responsibility to pay or have insurance cover it. Healthcare professional availability for certain services may be dependent on licensure, scope of practice restrictions, or other requirements in the state. The information provided is not a substitute for your doctor’s care and should be used as a practical guide to better health through lifestyle choices.

I hereby authorize the physicians and staff involved in SpecialtyHealth’s Wellness and Prevention Program and The Cummings Foundation For Behavioral Health to utilize my medical information obtained through the Wellness and Prevention Program for the purpose of research. Research may include individual case studies and/or compilations of group/population data, which may be published and/or presented in lectures. All personal and medical information will be kept confidential. A personal ID will be assigned to each individual participant to protect his/her privacy.

ACKNOWLEDGEMENT OF RECEIPT: I have received, or I have been provided the opportunity to receive a copy of the “Notice of Privacy Practices” that explains when, where, and why my confidential health information may be used or shared. I acknowledge that SpecialtyHealth Clinic, the physicians, the nurses, and other SpecialtyHealth staff may use and share my confidential health information with others in order to treat me, in order to arrange for payment of my bill, and for issues that concern SpecialtyHealth’s operations and responsibilities. I further acknowledge that I understand that if I have any questions regarding this Notice or wish to file a complaint, I may contact the SpecialtyHealth Privacy Officer in writing. I also understand that no other staff member, physician, nurse, or any other person is authorized to accept a request to exercise my rights but the Privacy Officer for SpecialtyHealth Clinic.

Notice of Privacy Practices
Federal law requires that we seek your acknowledgement of receipt of this Notice of Privacy Practices, effective April 14, 2003. Please signify your acknowledgement with your signature beneath the following statement (Release of Information to Someone Designated by The Patient):

Release of Information to Someone Designated by the Patient

According to the HIPAA compliance for Protected Health Information (PHI), it is necessary to provide SpecialtyHealth Clinic with name(s) of the following individual(s) with whom they may share my protected health information (PHI). It is with my informed consent that these individuals are able to speak with, be given written prescriptions and orders for procecure(s) and discuss health care; options if I am unable to do so. It is also my understanding that I may revoke this consent at any time; as long as the revocation is in writing with a signature, effective date and is received at the office of SpecialtyHealth.

SpecialtyHealth will not disclose my medical information to any person or entity unless I specifically authorize such disclosure in writing or SpecialtyHealth is required by law to make such disclosure.