Patient Name: 
 ​​​​​​Middle Initial:

Treatment: I hereby authorize Accordia to provide me with needed medical treatment and services by the Doctors and Certified Nurse Practitioners (CRNP) of this Primary Medical Care clinic. I understand that treatment and services may include lab tests, screening tests, diagnostic tests and routine exams.

Purpose of Consent for Disclosure: As part of my healthcare, Accordia Health originates and maintains health records describing my health history, symptoms, examinations, test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as: Notice of Privacy Practices: I have been furnished a copy of the Notice of Privacy Practices and have had it explained to me. I understand that the information concerning the treatment will be held in confidence by the Accordia staff unless I give specific written consent for the release of information. In case of emergency Accordia is authorized to request or release that information which is essential to handle the emergency. Also, Accordia staff will not release any information except as required by law or Court Order under compelling disclosure, or in a situation deemed potentially life-threatening, and in the following instances: Suspected Child Abuse, threats of physical harm to self and/or others, espionage or sabotage. The confidentiality of your participation may also be protected by federal and state laws and regulations. The violation of federal requirements is a crime, and suspected violations may be reported. Federal regulations do not protect from disclosure of information related to a Patient’s commission of a crime against Accordia property or personnel, or reports under state law of suspected child abuse or neglect (See 42 U.S.C. 290 ee 3 for federal laws 42 CFR Part 2 for federal regulations).

E-mail Communications: By signing below and providing the relevant contact information I consent to allow Accordia Health to communicate with me via e-mail. I understand that communications via e-mail may not be secure and my personal health information could be intercepted and breached. I agree that the company will not be liable for the protection of my health information that I have requested be communicated via e-mail.
E-mail address:
Cell phone number including area code: 

Consent for Residents, Interns, and Medical and Nursing Students to Participate in my Treatment: I am aware that, residents, interns, medical and nursing students, could be present for educational purposes. I understand that in the educational process they may observe or participate in my or my child’s treatment and/or review my or my child’s medical record.

Consent to Photographs: I consent to have my photograph taken by the staff at Accordia as part of the admission process. I understand that this photograph will be placed in my individual medical record in keeping with this facility’s system of Patient identification, and will be used for identification purposes only when necessary during the course of my treatment.

Right to Revoke: You have the right to revoke this Consent at any time by giving written notice of my revocation submitted to Accordia Health. Please understand that revocation of this Consent will not affect any action we took prior to this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

I, , have had full opportunity to read and consider the Consents of this consent form and your Notice of Privacy Practices. I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.
Signature of Patient

Reset Signature


If this Consent is signed by a personal representative on behalf of the patient, complete the following:

Name of Personal Representative:  
Signature of Personal Representative

Reset Signature


Relationship to Patient 

Created 5/6/2019; Revised electronically 4/28/2020