Wellness Possebilities, Lisa H. Hjelmstad, msw, lcsw, lmft consent for Purposes of Treatment, Payment & Healthcare Operations (10/2010)



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Wellness Possebilities, Lisa H. Hjelmstad, MSW, LCSW, LMFT
Consent for Purposes of Treatment, Payment & Healthcare Operations (10/2010)
In this document, “I” and “my” refer to the patient,

and “Provider” refers to Wellness Possebilities, Lisa H. Hjelmstad, MSW, LCSW, LMFT.


I consent to the use or disclosure of my protected health information by Wellness Possebilities, Lisa H. Hjelmstad, MSW, LCSW, LMFT for the purpose of testing, analyzing, diagnosing or providing treatment to me, obtaining payment for my health care services or to conduct health care operations of Wellness Possebilities, Lisa H. Hjelmstad, MSW, LCSW, LMFT specifically related to the screening for substance abuse. I understand that testing, analysis, diagnosis or treatment of me by Wellness Possebilities, Lisa H. Hjelmstad, MSW, LCSW, LMFT may be conditioned upon my consent as evidenced by my signature below.
I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Posse Partners is not required to agree to the restrictions that I may request. However, if Wellness Possebilities, Lisa H. Hjelmstad, MSW, LCSW, LMFT agrees to a restriction that I request, the restriction is binding on Wellness Possebilities, Lisa H. Hjelmstad, MSW, LCSW, LMFT. I have the right to revoke this consent, in writing, at any time, except to the extent that Wellness Possebilities, Lisa H. Hjelmstad, MSW, LCSW, LMFT has taken action in reliance on this Consent.
My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.
I have been provided with a copy of the Notice of Privacy Practices of Wellness Possebilities, Lisa H. Hjelmstad, MSW, LCSW, LMFT and understand that I have a right to review the Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Wellness Possebilities, Lisa H. Hjelmstad, MSW, LCSW, LMFT. The Notice of Privacy Practices for Wellness Possebilities, Lisa H. Hjelmstad, MSW, LCSW, LMFT is available to you any time I present myself for services. This Notice of Privacy Practices also describes my rights and duties of the Provider with respect to my protected health information.
Wellness Possebilities, Lisa H. Hjelmstad, MSW, LCSW, LMFT reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. Any change will be posted in the facility and I may obtain a revised notice of privacy practices by calling the office of Wellness Possebilities, Lisa H. Hjelmstad, MSW, LCSW, LMFT and requesting a revised copy be sent in the mail or asking for one at any time I am in for services.

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Signature of Patient or Personal Representative Printed Name of Patient
________________________________ __________________________________________

Date of Signing Description of Personal Representative’s Authority


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