Call Us! (718) 769-2521

3500 Nostrand Ave, Brooklyn, NY 11229

Request an appointment

HQBK

General Consent Form

GENERAL CONSENT TO USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

If applicable your protected health information will be used by Finally Health Medical Services, PC (FHMS) or disclosed to others, including the case manager and/ or medical review officer at Fed-Ex/ UPS, as per our agreement with them, for the purpose of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice.

You should review the Notice of Privacy Practices for a more complete description of how your protected health information may be used or disclosed. You may review the notice prior to signing this consent.

You may request a restriction on the use and disclosure of your protected health information. FHMS may or may not agree to restrict the use or disclosure of your protected information. If FHMS agrees to the request, the restriction will be binding on the practice. Use or disclosure of protected information in violation of an agreed upon restriction may be a violation of the federal privacy standards.

You may revoke this consent to the use and disclosure of your protected health information.You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date in which you revoke this consent will not be affected.

FHMS reserves the right to modify the privacy practices outlined in the notice.

FHMS takes every precaution to keep all of my information confidential and that that the only times it uses or discloses any of my protected health information, it is done so with the minimal amount necessary to achieve the desired result.

There may be a situation where it may be legally mandated that my information be released to the proper authorities. In this case, I understand that FHMS has no choice but to adhere to the legal mandate.

FHMS has a policy to advise close family members as to my protected health information. If you do not consent to this check off below asking this office not to do so.


Do not release my information to any family members.

I understand that I am entitled to review my information at any time. I consent that if I request copies of any records, that there may be a reasonable charge for them which I am responsible for.

I have reviewed this consent form and give my permission to FHMS to use and disclose my health information in accordance with it.

I request that payment of authorized (carrier) benefits be made on my behalf to Finally Health Medical Services for services furnished to me by the provider.

Verification Code