Phone:

210-692-1245

Address:

3603 Paesanos Parkway, Suite 300, San Antonio, TX 78231

New Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operations


I,

understand that as part of my healthcare, this office originates and maintains paper and/or electronic records describing my health history, symptoms, examination, and test results, diagnoses, treatment, and any plans for future care or treatment.

I understand that this information serves as:

  • A source for planning my care and treatment.
  • A means of communication among the many health professionals who contribute to my care.
  • A source of information for applying my diagnosis and surgical information to my bill.
  • A means by which a third‐party payer can verify that services billed were actually provided.
  • A tool for routine healthcare operations such as assessing quality and reviewing the competence of health care professionals.

I have been provided with a summary Notice of Information Practices that provides a more complete description of the uses and disclosures of my health information. I understand that I have rights under the HIPAA regulations. I may revoke this consent at any time, provided that such revocation is in writing and presented to any of the office staff.

I understand that Neurology Institute of San Antonio has established a Notice of Privacy Practices which provides information about how a patient's protected health information, including Rx and billing, can be used and disclosed. I consent to the use of my protected health information for the treatment, payment, and health care options.

I give you permission to call, speak with, and/or release any health information to the following person(s):

 

I fully understand and accept terms of this consent.

Please read this important note from Dr. Van Delden regarding close of practice.