Rev. 2/2018
Consent to the Use and Disclosure of Health Information for
Treatment, Payment or Healthcare Operations
Patient Name: ___________________________________ Date of Birth: _____________________
I understand that as part of my healthcare, the Houston County Health Department originates and maintains
health records describing my health history, symptoms, examination and test results, diagnosis, treatment and
any plans for future care or treatment. I understand this information serves as:
• A basis 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 treatment information to my bill,
• A means by which a third-party payer can verify that services billed were actually provided, and
• A tool for routine healthcare operations such as assessing quality and reviewing the competence of
healthcare professionals.
I have been provided with a Notice of Privacy Practices that provides a more complete
description of information uses and disclosures.
I understand that:
• I have the right to review the notice prior to signing this consent.
• The organization reserves the right to change its notice and practices
• I will receive a revised notice at my next visit if any revisions are made to the notice.
• I have the right to object to the use of my health information for directory purposes.
• I have the right to request restrictions as to how my health information may be used or disclosed to
carry out treatment, payment, or healthcare operations and that the organization is not required to
agree to the restrictions requested.
• I may revoke this consent in writing, except to the extent that the organization has already taken
action in reliance thereon.
I wish to have the following restrictions to the use or disclosure of my health information:
_________________________________________________________________________________________
_________________________________________________________________________________________
__________________________________________ ____________________ _____________
Signature of Legal Representative of Patient Named Relationship to Patient Date
____________________________________ _________________ ___________
Witness Title Date
Houston County Health Department
Travel Clinic
98 Cohen Walker Dr., Warner Robins, GA 31088
Phone: 478-218-2000
Fax: 478-201-2017
NCHD52.org/Travel
