New Patient Form
Patient Consent Form
Insurance

Patient Consent Form

All patients must have on file with us a consent form for use and disclosure of protected health information. You may either print out a pdf of the form by clicking here or you may complete the form below and submit electronically.

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Patient Consent for Use and Disclosure of Protected Health Information

In signing this form, you consent to the use and disclosure of your protected health information by Chris Gayden, D.O., our staff, and our business associates strictly for the purpose of treatment, payment and health care operations.

You acknowledge you have had the opportunity to review our NOTICE OF PRIVACY PRACTICES carefully. It provides more detail on how we may use and disclose your information. The NOTICE OF PRIVACY PRACTICES may change. A current copy may be requested when you are being seen as a patient, or by contacting our manager at 972.831.8000.

You may request that we restrict how we use and disclose your protected health information for the purposes mentioned above.  If you would like to request a restriction, please do so in writing. However, we reserve the right to deny your request. If we grant your request, we are bound by the terms of the agreement.

You may also revoke this consent in writing; however, information on any treatment/service provided using this or prior consents may still be used or disclosed for purposes of treatment, payment, or health care operations. Refer to the NOTICE OF PRIVACY PRACTICES for further information.

By signing this form, I grant my consent to the medical practice use and disclose my protected health information for the purposes of treatment, payment, and health care operations.