Patient Consent for Use and Disclosure of Protected Health Information

I hereby give my consent for Tara Acupuncture to use and disclose protected health information (PHI) about me to carry out treatment, payment, and health care operations (TPO). The Notice of Privacy Practices provided by Tara Acupuncture describes such uses and disclosures more completely.

I have the right to review the Notice of Privacy Practices prior to signing the consent. Tara Acupuncture reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Tara Vega Castro L. Ac.

With this consent, Tara Acupuncture may call my home or other alternative location and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.
With this consent, Tara Acupuncture may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential”.

With this consent, Tara Acupuncture may email to my home or other alternative 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 Tara Acupuncture restricts how it uses or discloses my PHI to carry out TPO. The practice is not required to agree with my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to allow Tara Acupuncture to use and disclose my PHI to carry out TPO.

I may revoke my consent in writing except to the extent of the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Tara Acupuncture may decline to provide treatment.

If you would like to printed version of this form, please click here.