Consent and Authorization of Treatment | Forme Medical Center

Consent Form

Authorization for Access to Patient Information Through a Health Information Exchange Organization

I request that health information regarding my care and treatment be accessed as set forth on this form. I can choose wheter or not to allow the Organization named above to obtain access to my Medical Records through the health information exchange organization called Health Connections. If I give consent, my Medical Records from different places where I get health care can be accessed using a statewide computer network. Health Connections is a non-for-profit organization that shares information about people's health electronically and meets the privacy and security standards of HIPPA and New York State Law. To learn more visit Health Connections website at http://healtheconnections.org/. The Choice I make on this form will NOT affect my ability to get medical care. The choice I make on this form does NOT allow health insurers to have access to my information for the purpose of deciding wheter to provide me with health insurance coverage or pay my medical bills.

First Name

Last Name

Date of Birth

Email address

Mobile phone number

MY CONSENT CHOICE

I GIVE CONSENT for the Organization named above to access ALL of my electronic health information through Health Connections to provide health care services (including emergency care)

I DENY CONSENT for the Organization named above to access ALL of my electronic health information through Health Connections for any purpose, even in a Medical Emergency.

Denying Consent

Authorization of Treatment

Patient or Patient's Legal representative agrees to the following terms of treatment:

Authorization:

I authorize

I do not authorize

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Consent Form and Authorization of Treatment

Authorization for Access to Patient Information Through a Health Information Exchange Organization

Authorization of Treatment

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