Bay Area Neurology has implemented the following policies and procedures so that the confidentiality of your personal and/or medical information remains confidential. Your physician(s) and all other employees working in Bay Area Neurology will keep any information related to you (medical and/or non-medical), in a confidential manner. However, so that we may provide you with appropriate medical care, for general practice operations and or for the purposes of obtaining payment, we will, at our discretion provide information pertaining to the treatment you received in this practice, tile charges for this treatment and related information regarding the treatment and charges to other health care related entities. This information will be submitted through the following mechanisms: US Postal Service, fax submission, Internet submission, voice mail and/or personal communications. The following is a list of the most common types of entities that we most typically would provide personal health related information. This list is not an all-inclusive list. Other entities may be added to this list.
We may need to contact you, by phone, to discuss or confirm your appointments, test results, treatments, referrals, an account balance and/or to return your phone call. We will first attempt to contact you at home, however, if you are not available, and you provide us with a work number, we will attempt to contact you at work. If you are not available, we will leave a message for you to either call, the office or we will remind you of your appointment time. These messages are sometimes left on personal message devices, such as an answering machine. If you do not want messages left on machines for you, please give us this in writing. Bay Area Neurology will use your health related information for the purposes of providing you will medical treatment, obtaining payment for services rendered and/or for general health care operations. Your health related information will be submitted through the following mechanisms: US Postal Service, fax submissions, Internet submissions, voice mail and/or personal communications. The most common entities that will receive this information are: other providers, facilities, insurance companies and pharmacies. More specific information pertaining to our practice policies is provided for you in our Notice of Privacy Practices statement. You have a right to review this statement prior to receiving health care and prior to signing this consent. The terms of our Notice of Privacy Practices may change, at any time. You may contact the office and request a revised policy. Also, if you so choose, you may request that we restrict the use of your health information for the purpose of treatment, payment and/or health care operations. We are not required to agree with your requested restrictions. In the event we do agree with your requested restrictions, we will adhere to these restrictions. If we do not agree with your request, we will discontinue treatment. I have received a copy of the practice's Notice of Privacy Practices. ______________ (Initial) I understand that I may revoke, at any time, this consent. This revocation will not effect previous actions, prior to the revocation. ________________ (Initial) I consent to the above terms related to the use and disclosure of my individually identifiable health information for the purposes of treatment, payment and/or health care operations. I understand that this consent will remain in effect until I revoke it, in writing. Patient Name (Print): _____________________________________ Date: _________________ Patient (or Patient's Representative) Signature: _______________________________________ Witness Signature: _____________________________________________________ 
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