NON-PATIENT CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR

TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS

1. I understand that the following test results will be placed in my spouse/partner's chart at Rapid City Medical Center, LLP and will become a part of their medical record.
2. I agree to the following by initialing the appropriate box and signing below. I also understand that I may revoke this consent in writing, except to the extent that Rapid City Medical Center, LLP has already taken action in reliance thereon. This signed consent shall remain in force until the undersigned non-patient gives written notification, stating otherwise.

Test 1

Semen Analysis

Test 2

RH Factor (Blood Typing)

Test 3

Chromosome Studies

Test 4

Other

Test 5

Other Information

Reporting to Self

3. I agree to the following reporting of my test results.

My test results may be given to my spouse/partner.


Spouse/partner's Name


Spouse/partner's Date of Birth
   

My test results may be reported only to me.

Reporting to Spouse/Partner

4. In the event that my spouse/partner is referred to another specialist for further care:

I agree to have a copy of the above-initialed test result sent.


I do not agree to have the above-initialed test results sent.


Name


Patient's Date of Birth