Patient Authorization of Disclosure | Neurology Consultants of Nebraska

In general, the HIPAA Privacy Rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home. The patient may revoke or change this authorization at any time with a written request.

I wish to be contacted in the following manner (Check all that apply):*

Home Telephone
Work Telephone
Written Communication
Other

Home Phone*

How do you want us to leave a message?*

Work Phone*

How do you want us to leave a message?*

Where do you want it sent?*

OK to mail to my home address
OK to mail to my work/office address
OK to fax

Fax Number

If Other, Please specify below

In a further effort to protect your health information and the confidentiality of you healthcare, we ask that you designate below to whom the physicians and staff at Neurology Consultants of Nebraska, P.C. may discuss your healthcare and scheduling needs as well as billing issues that may arise.

I allow you to give my clinical and/or financial information to or answer questions from (Check all that apply)

Spouse
Parent
Child
Other (specify)
Only disclose information to myself

Spouse Name

First Last

Parent Name

First Last

Child Name

First Last

If Other, please specify below

At any time you may revoke or terminate this authorization by submitting a written revocation to Neurology Consultants of Nebraska, P.C. However, your written revocation will not affect any disclosures of your medical information that the person(s) and/or organization(s) listed above have already made, in reliance of this authorization, before the time you revoke it.

Patient Signature (Type Your Name)*

Today's Date*

Your Date of Birth*