Hipaa-NPP Consent

Fields with a red asterisks are required fields and must be completed to proceed. If you are unable to complete online, we will ask you to complete the forms at the time of your appointment.

Health Care Consent/Personal Belongings/NPP Acknowledgment/Phone Messages Authorization/Authorized Representatives

Patient Name: *

Date of Birth:

Consent to Evaluate/Treat: I, for myself, or the patient named above, hereby consent to such medical evaluation (e.g. impairment rating, IME) and/or treatment and diagnostic procedures (e.g. x-rays, MRI, videotaping) as necessary and appropriate for my condition or illness based on the judgment of my physician(s), to be performed by the physician(s), physician assistant(s), nurse(s) or other health care provider(s). I have had, and will continue to have, an opportunity to discuss treatment options with my healthcare provider, ask questions regarding such treatment options and understand the options discussed. I understand there may be additional risks associated with COVID-19 as well as any public health emergency. I further understand IBJI has implemented employee and patient safety protocols to reduce the risk of spreading COVID-19, and I agree to notify staff prior to any appointment of any fever, symptoms or exposure. Initial box that you consent to medical treatment by IBJI. Initial box that you consent to medical treatment by IBJI.

The Notice of Privacy Practice (NPP) tells you how we may use and share your health records. It also describes your rights with respect to your health records. Please read it.
• We will use and share your health records to treat you and to bill you for the services we provide.
• We will use and share your health records for your treatment purposes.
• We will use and share your health records to run our business.
• We will use and share your health records as required/allowed by law.
I understand that the NPP is available on the Illinois Bone and Joint Institute website (www.ibji.com) and at my physician’s office. By initialing here, I acknowledge receipt of the IBJI Notice of Privacy Practices.

Personal Belongings: I assume full responsibility for all items of personal property that I have brought to IBJI and release IBJI of all liability in the event of loss or damage to such property.

Initial box that you assume full responsibility for your personal property:

Phone Message/Contact Authorization: : Do the physicians and staff of Illinois Bone and Joint Institute have your permission to leave messages containing medical and/or financial information on your answering machine?

At home At work On cell

Yes

* IF YOU CHECK “NO”, THE DATE, TIME AND LOCATION OF APPOINTMENTS WILL BE LEFT ON YOUR ANSWERING MACHINE.

Authorized Representatives: The individual(s) named below will also be your emergency contact(s) unless you specify otherwise. Please complete below: I give authorization to the doctors and staff of Illinois Bone and Joint Institute to discuss my medical and/or financial information with the following people:

Name

Relationship

Phone

I understand that it is my responsibility to inform IBJI of any desired changes in this authorization. Note: This consent/authorization expires one year after the date of signature.

Signature of Patient:

I agree that my electronic signature will have the same effect as an original handwritten signature.

I have read this Electronic Record and Signature Disclosure.

Choose alternative style

Signature of Authorized Representative:

I agree that my electronic signature will have the same effect as an original handwritten signature.

I have read this Electronic Record and Signature Disclosure.

Choose alternative style

Date

Authorized Representative Name Printed:

Relationship of Authorized Representative: