I hereby give my consent for Systemedx to use and disclose protected health information about me to carry out treatment, payment, and health care operations. (The Notice of Privacy Practices provided by describes such uses and disclosures more completely.)

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect my privacy. I have the right to review the Notice of Privacy Practices prior to signing this consent. Systemedx 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 the address above.

With this consent, Systemedx 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 health care operations, such as appointment reminders, insurance items, and any calls pertaining to my clinical care, including laboratory test results, among others.

With this consent, Systemedx may mail to my home or other alternative location any items that assist the practice in carrying out health care operations, such as appointment reminder cards and patient statements as long as they are marked personal and confidential.

With this consent, Systemedx may e-mail to my home or other alternative location any items that assist in carrying out health care operations, such as appointment reminders and patient statements.

With this consent, Systemedx, its employees and/or agents "express prior consent" to contact me at any/all phone numbers, including cell phone numbers (by phone call or text message), for the purpose of treatment, insurance and/or payment.

I have the right to request that Systemedx restricts how it uses or discloses my personal health information to carry out health care operations. 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 Systemedx to use and disclose my personal health information to carry out health care operations.

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, Systemedx may decline to provide treatment to me.





Standard version