I acknowledge that I have reviewed Vein Specialists of the Carolinas Notice of Privacy Practices and have been given an opportunity to ask questions. I may request a copy of the Privacy Practices for my records.
Patient Name ________________________________________________________________
(Please Print)
_______________________________________________ ___________________________
Signature of Patient or Guardian Date
___________________________________________________________________________
If Guardian, give relationship to patient
I have agreed to let certain individuals participate in discussions and decisions related to my medical care. Therefore, I hereby give my permission for Vein Specialists of the Carolinas staff to disclose my personal medical information to the following individual:
Name: _________________________________________ Relationship to Patient ________________________
Name: ______________________________________ Relationship to Patient______________________
Conditions for Disclosure (Check the item(s) that apply):
¨ The practice may disclose my personal health information to the individual(s) above only in my presence.
¨ The practice may disclose my medical information to the individual(s) above in discussions in my presence and when I am not physically present, including disclosures by telephone, facsimile or e-mail or regular mail.
¨ Other Conditions of Disclosure: _______________________________________________________
_________________________________________________________________________________________
I understand that this consent may be revoked by me at any time by written notice to the practice.
Acknowledgement of Patient Rights & Responsibilities and Advanced Directive Policy:
A copy of the Patient Rights & Responsibilities and the policy for honoring advance directives in this outpatient facility have been made available to me for review. I understand that if I have a living will or Do Not Resuscitate Order that it will be suspended for any outpatient elective procedure that is completed in this center.
Patient Name: _______________________________________________________________
(Please Print)
Signature of Patient: _____________________________________Date:_________________
Witnessed by: __________________________________________ Date:_________________
