YOUTH CARE/SAME DAY CARE

Patient Consent For Use and Disclosure
of Protected Health Information


With my consent, Youth Care/Same Day Care may use and disclose protected health information (PHI) about my children to carry out treatment, payment and healthcare operations (TPO) Please refer to Youth Care/Same Day Careís Notice of Privacy Practices, posted in each waiting room, for a more complete description of such uses and disclosures.


I have the right to review the Notice of Privacy Practices prior to signing this consent. Youth Care/Same Day Care reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Linda Horton, Privacy Officer at 525 E. Blue Starr Dr. Claremore, OK. 74017.


With my consent, Youth Care/Same Day Care may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including lab results among others.


With my consent, Youth Care/Same Day Care may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Youth Care/Same Day Care restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.


By signing this term, I am consenting to the practices use and disclosure of my PHI to carry out TPO.


I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent, the practice may decline to provide treatment to me.
 

_____________________________  
Signature of Legal Guardian  
   
_____________________________ __________________
Patientís Name Date
 
YOUTH CARE / SAME DAY CARE may release my information to the person listed below:
 
_____________________________ __________________
               Name Relationship