I
understand that as part of my (or my child’s) New Patient
Intake Evaluation, Mercy Family Center originates and maintains
paper and/or electronic records describing my (or my child’s)
health history, symptoms, examination and test results, diagnoses
and treatment. I understand that this information serves as:
• A basis for evaluating potential care
and treatment,
• A means of communication among the Mercy Family Center clinical staff
who may be asked to contribute to my (or my child’s) care,
• A means by which a third-party payer can verify that services being considered
are covered under my (or my child’s) health plan.
I understand that the information I provide
will be used only by Mercy Family Center staff and disclosed
only to a third party payor to verify my insurance coverage
during this intake evaluation process. I understand that
if I (or my child) is accepted as a patient by Mercy Family
Center, I will be asked to sign a New Patient Consent Form
and will be provided with a Notice of Information Practices
that details a complete description of protected health information
uses and disclosures by Mercy Family Center. I understand
that if I (or my child) am not accepted as a patient, all
protected health information I have provided to Mercy Family
Center will be destroyed. No record of my intake evaluation
will be retained by Mercy Family Center.
I understand that I have a right to decline
this consent. I also understand that by declining this consent,
Mercy Family Center may refuse to treat me as permitted by
Section 164.506 of the Code of Federal Regulations.
I fully understand and accept (per location)
/ decline the terms of this consent.
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