DeptFord Medical Center



General consent for Examination and Treatment:

I here consent and authorize all physicians and medical personnel, to perform medical examinations and provide routine medical care for all visits. This may include routine diagnostic and laboratory procedures and tests, medication administration, and other routine care for which a specific informed consent form will not be signed by me. This consent includes consent and authorization to photograph or otherwise take images of me/or parts of my body for purposes of identification, diagnosis, treatment, payment and health operations. Any photographs or other images taken will become part of my medical record.

Acknowledge of receipt of Notice of Privacy Practices:

I have read and understand HIPAA Notices of Privacy Practices, which contains information on the uses and disclosures of my Protected Health Information (PHI). I understand the right to change its HIPAA Notice of Privacy Practices from time to time and that whenever as Important change is made The Deptford Medical Center will post a new notice in the office. I may contact The Deptford Medical Center at any time to obtain a certain copy of the HIPAA Notice of Privacy Practices.

Consent to use and disclose Protected Health Information for treatment, payment and Health Care Operations:

I hereby consent and authorize to use and disclose my health information, which includes all or any part of my Medical Records. I Understand that, for example, my health information may be used or disclosed to provide for my care and treatment, communicate among various health care professionals who are involved in my care or treatment, to bill or obtain payment for care, and conduct its business and health care operation. In addition, I Understand they may release my protected health information as required by law or court order.

I acknowledge receipt of Notice of Privacy Practices.