The below listed persons may obtain and discuss my confidential medical information about me. I may rescind this authorization by submitting a written request to paradise valley Foot & Ankle, PLLC.
Person(s) to receive my confidential medical information:
A copy for your review is available at the front desk.
I have reviewed a copy of the Notice of Privacy Practices, which became effective in April 2003. This notice describes how much medical information about me may be used and disclosed and how I can get access to this information.
Patient Rights
Access: The patient has the right to look at or get copies of his/her protected health information, with limited exceptions. The patient must make a request in writing to the contact person listed to obtain access to his/ her protected health information. If copies are requested, the fee, to be paid in advance, will be 1.15 for each page, and $25.00 per hour for staff time to locate and copy the protected health information. The patient will be notified when the documents will be ready for the patient to pick up at the doctor's office.
Please sign your name in the area below