The Childrens Clinic of Nashville, P.L.C.

Patient Consent for Use And Disclosure

Of Protected Health Information

With my consent, The Childrens Clinic of Nashville may use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operations (TPO). Please refer to The Childrens Clinic of Nashville’s Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review and/or obtain a copy of the Notice of Privacy Practices prior to signing this consent. The Childrens Clinic of Nashville 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 The Childrens Clinic of Nashville Privacy Officer at 4322 Harding Road, Ste. 313, Nashville, TN 37205.

With my consent, The Childrens Clinic of Nashville 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.

With my consent, The Childrens Clinic of Nashville may mail to my home 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.

I have the right to request that The Childrens Clinic of Nashville 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 form, I am consenting to The Childrens Clinic of Nashville’s use and disclosure of my protected healthcare information to carry out treatment, payment, and healthcare operations. 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, The Childrens Clinic of Nashville may decline to provide treatment to me.