CARENOW URGENT CARE
PATIENT HIPAA ACKNOWLEDGMENT AND CONSENT FORM
Patient Name (Printed): _ _ Date of Birth: _
Notice of Privacy Practice/clinics
_ (Patient/Representative initials) I acknowledge that I have received the practice’s/clinic’s Notice of
Privacy Practice, which describes the ways in which the practice/clinic may use and disclose my healthcare
information for its treatment, payment, healthcare operations and other described and permitted uses and
disclosures, I understand that I may contact the Privacy Officer designated on the notice if I have a question or
complaint. I understand that this information may be disclosed electronically by the Provider and/or the Provider’s
business associates. To the extent permitted by law, I consent to the use and disclosure of my information for the
purposes described in the Notice of Privacy Practice.
Release of Information.
I hereby permit practice/clinic and the physicians or other health professionals involved in the inpatient or outpatient
care to release healthcare information for purposes of treatment, payment, or healthcare operations.
Healthcare information regarding a prior service(s) at other HCA affiliated providers may be made available to
subsequent HCA-affiliated providers to coordinate care. Healthcare information may be released to any person
or entity liable for payment on the Patient’s behalf in order to verify coverage or payment questions, or for any
other purpose related to benefit payment. Healthcare information may also be released to my employer’s
designee when the services delivered are related to a claim under worker’s compensation.
If I am covered by Medicare or Medicaid, I authorize the release of healthcare information to the Social Security
Administration or its intermediaries or carriers for payment of a Medicare claim or to the appropriate state
agency for payment of a Medicaid claim. This information may include, without limitation, history and physical,
emergency records, laboratory reports, operative reports, physician progress notes, nurse’s notes,
consultations, psychological and/or psychiatric reports, drug and alcohol treatment and discharge summary.
Federal and state laws may permit this facility to participate in organizations with other healthcare providers,
insurers, and/or other health care industry participants and their subcontractors in order for these individuals
and entities to share my health information with one another to accomplish goals that may include but not be
limited to: improving the accuracy and increasing the availability of my health records; decreasing the time
needed to access my information; aggregating and comparing my information for quality improvement
purposes; and such other purposes as may be permitted by law. I understand that this facility may be a member
of one or more such organizations. This consent specifically includes information concerning psychological
conditions, psychiatric conditions, intellectual disability conditions, genetic information, chemical dependency
conditions and/or infectious diseases including, but not limited to, blood borne diseases, such as HIV and AIDS.
Disclosures to Friends and/or Family Members.
DO YOU WANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM THE
PROVIDER MAY DISCUSS YOUR MEDICAL CONDITION? IF YES, WHOM?
I give permission for my Protected Health Information to be disclosed for purposes of communicating results,
findings and care decisions to the family members and others listed below:
Patient/Representative may revoke or modify this specific authorization and that revocation or modification must be in writing.
Consent for Photographing or Other Recording for Security and/or Health Care Operations
I consent to photographs, digital or audio recordings, and/or images of me being recorded for patient care, security
purposes and/or the practice’s/clinic’s health care operations purposes (e.g., quality improvement activities). I
understand that the practice/clinic retains the ownership rights to the images and/or recordings. I will be allowed to
request access to or copies of the images and/or recordings when technologically feasible unless otherwise
prohibited by law. I understand that these images and/or recordings will be securely stored and protected. Images
and/or recordings in which I am identified will not be released and/or used outside the facility without a specific
written authorization from me or my legal representative unless otherwise permitted or required by law.
Name Relationship Contact Number