PATIENT CONFIDENTIALITY Patient Confidentiality PF-2000 Patient Consent for Use and Disclosure of Protected Health Information, and Notice of Privacy Practices.I hereby give my consent for T.E.Q. & Associates, Inc. to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TP0). The Notice of Privacy Practices provided by T.E.Q. & Associates, Inc, describes such uses and disclosures more completely. I have the right to review the Notice of Privacy Practices prior to signing this consent. T.E.Q. & Associates, Inc. reserves the right to revise its Notice of Privacy Procedures at any time. A revised Notice of Privacy Practices may be obtained by written or oral request to the Receptionist or HIPAA Coordinator. With this consent, T.E.Q. & Associates, Inc. may call my home or other alternative 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 calls pertaining to my clinical care, including labora-tory test results, among others. With this consent, T.E.Q. & Associates, Inc, may mail to my home or other alternative location any items that assist in the practice carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that T.E.Q. & Associates, Inc. restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to allow T.E.Q, & Associates, Inc. to use and disclose 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. If I do not sign this consent, or later revoke it, T.E.Q. & Associates, Inc. may decline to provide treatment to me. T.E.Q. & Associates, Inc. reserves the right to modify the privacy practices outlined in the notice. Signature: I have reviewed a copy of the Notice of Privacy Practices for T.E.Q & Associates, Inc T.E.Q. & Associates, Inc. — A Professional Corporation Teresa E. Quinlin, M.D. 28 E. Waterloo St./P.O. Box 206 Canal Winchester, OH 43110 (614)833-1500 Phone Message Consent Form Notice of Privacy Practice- Patient Acknowledgment We, at T.E.Q. & Associates, are committed to safeguarding the privacy and confidentially of your medical records including the personal information that you with us. We comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). From time to time it may be necessary or desirable to contact patients by phone. To expedite your health care and in the interest of convenience, if you to not available to speak with us directly, we would like to leave a message whenever possible. To assist us in protecting your privacy, please complete the following:Patient Name*I wish to be contacted in the following manner:Home Phone*Leave a detailed voice mail message?*YesNoLeave a message with call back number?*YesNoWork PhoneMay we call you at work?*YesNoLeave a detailed voice mail message?*YesNoLeave a message with call back number?*YesNoCell PhoneLeave a detailed voice mail message?*YesNoLeave a message with call back number?*YesNoOther RequestMay we speak to someone else regarding your medical careYesNoName of PersonPhone NumberName of PersonPhone NumberI understand that I may revoke this consent at any time.WitnessDate This iframe contains the logic required to handle Ajax powered Gravity Forms.