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ACKNOWLEDGEMENT OF RECEIPT OF BSHC NOTICE OF PRIVACY

And AUTHORIZATION TO RELEASE HEALTH INFORMATION TO SPECIFIED INDIVIDUALS

Child's Name:

Choose School:

Date of Birth:

Grade:

Big Sandy Health Care, Inc. (BSHC) may need to use your name, mailing address, email address, phone number and your clinical records to contact you regarding information about treatment or other health related information that may be of interest to you. If this contact is made by phone and you are not available, a voice mail message will be left on your phone and/or with the persons authorized below. By signing this form, you are authorizing BSHC to contact you concerning this medical information and disclose limited protected health information to other persons who may answer your electronic communications such as phone, text messages, or email.

Patient Consent to Share Personal Health Information
Please check which information Big Sandy Health Care, Inc., is authorized to share with each person listed below.

Name:

Phone Number:

Date of Birth:

Type of Information to be Released:

Medical

Billing

Scheduling

All

Name:

Phone Number:

Date of Birth:

Medical

Billing

Scheduling

All

Name:

Phone Number:

Date of Birth:

Type of Information to be Released:

Medical

Billing

Scheduling

All

Email and text messages (SMS) are convenient ways for us to communicate, but they are not secure or private. Your messages can be read by or forwarded to others, either intentionally or by mistake. By signing below, you agree to the following:

I understand that email, text messages, video/voice chat, and other electronic communications are not private nor secure in all circumstances and by signing below, I give my permission for BSHC to use electronic communications to share my personal health information with me, the people I have listed above, and other providers who are an integral part of my care as determined by myself or my primary care provider. I understand that this will involve using third party services to facilitate these communications. I agree to hold BSHC harmless for errors involving the leaving messages through e-mail, text messages, video/voice chat and other electronic communications that are not encrypted and secure. I understand that BSHC participates in the Kentucky Health Information Exchange and part of my health record will be sent to this community agency responsible for public health information.

I understand I may restrict the individuals to whom my healthcare communication is released. I further understand I may restrict organizations which can receive my health care information. I, understand I may revoke this authorization at any time. My written revocation must be submitted to the HIPAA Privacy Officer at: Big Sandy Health Care, 1709 Ky. Rte 321 Suite 3, Prestonsburg, Ky., 41653. The written revocation cannot be honored until it has been physically received by BSHC.

I understand that information I allow to be disclosed may be subject to re-disclosure by others who have access to the information and may no longer be protected by federal privacy rules.
I understand I have the right to refuse this authorization and this refusal shall not affect my care with any Big Sandy Health Care clinic.

I have fully read this document I do hereby authorize BSHC to use and/or disclose my health information in the manner described above. My signature indicates my approval for BSHC to send appointment and care reminders. I, understand I have the right to revoke this approval in writing. I, understand my cell phone carrier may charge me for such reminders and I shall be responsible for payment. I also understand that I have access to a copy of Patient Rights & Responsibilities and BSHC’s Privacy Notice located at www.bshc.org. I may request a copy by calling BSHC at (606) 886-8546.

PARENT/GUARDIAN: TYPE YOUR FULL NAME

REQUIRED: Use your mouse or touchscreen device to obtain signature below and click Submit Form.

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