KESPARA MEDICAL CENTER
22 Meridian Rd, Suite 10 Edison, NJ 08820
22 Meridian Rd, Suite 10 Edison, NJ 08820
Pullin Patel,MD
Internal Medicine
Ph:(732) 243-9808
Fax:(732) 791-5765
Patient Authorization for Use & Disclosure of Protected Health Information
By signing, I authorize Kespra Medical Center LLC to use and/or disclose certain protected health information(PHI) which specifically identifies me or which can reasonably be used to identify me to carry out my treatment , payment and health care operations.
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This authorization permits Kespra Medical Center LLC to use and/ or to disclose the following individually identifiable health information about me (specially describe the information to be used or disclosed , such as date(s) of services, type of services, level of details to be released, origin of information etc.
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The information will be used and disclosed for the following purpose:
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(If disclosure is requested by the patient, purpose may be listed as "at the rest of the individual.")
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The purpose(s) is/are provided so that I can make an informed decision whether to allow release of the information.
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I understand that while this consent is voluntary, if I refuse to sign this consent , Kespara Medical Center LLC would refuse to treat me.
In fact, I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization , it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA privacy rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the privacy officer at:
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Kespra Medical Center
22 Meridian Rd, Suite 10
Edison, NJ 08820
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Signed by:
Signature of patient or legal guardian
Relationship to Patient
Print Patient's Name:
Date:
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Print name of Patient or Legal Guardian , if applicable
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