Columbia Woods Medical Group Diamond Family Practice Fairlawn Family Practice Family Practice Associates Family Practice Center of Wadsworth Great Trail Family Practice Hearthstone Family Practice Internal Medicine of Green Internal Medicine West Louisville Medical Center Medina Primary Care North Canton Family Physicians Northampton Primary Care Northeast Family Health Care Ohio Family Practice Pioneer Foot & Ankle Care South Main Street Medical Center Springfield Primary Care Springside Internal Medicine Stow-Hudson Primary Care
Date of Birth
Last 4 of SS#
I hereby authorize Pioneer Physicians Network, Inc. to use and disclose my individually identifiable health information as described below. I understand that this authorization is voluntary and that it may include information relating to AIDs, HIV Infection, behavioral health services, psychiatric care, and treatment for alcohol and/or drug abuse. I understand that if the organization authorized to receive the information is not a health plan or health care provider; the released information may no longer be protected by Federal Privacy Regulations. I understand that I need not sign this authorization to ensure treatment and that I may inspect or copy the information to be used or disclosed as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for unauthorized re-disclosure and the information may not be protected by Federal Confidentiality Rules.
I give permission to the staff and physicians of Pioneer Physicians Network, Inc. to leave detailed phone messages.
I consent and state my preference to have the staff and physicians of Pioneer Physicians Network, Inc communicate with me by standard SMS (text) messaging and email regarding various aspects of my medical care, which may include, but shall not be limited to, test results, prescriptions, appointments, and billing. I understand that standard SMS messaging and email are not a confidential method of communication and may be insecure. I further understand that, because of this, there is a risk that standard SMS messaging and email regarding my medical care might be intercepted and read by a third party.
I give permission to the staff and physicians of Pioneer Physicians Network, Inc to share protected health information with designated individuals. If yes, please list individuals below and indicate the type of information that can be disclosed.
1. Name and Relationship To Patient
1. Phone Number
2. Name and Relationship To Patient
2. Phone Number
3. Name and Relationship To Patient
3. Phone Number
Information to be shared:
I certify that I have read the provisions of this authorization, understand the content, and agree to the terms set forth within the authorization. I understand that this authorization is valid for one year from signature date unless there is a Power of Attorney or Durable Healthcare Power of Attorney on file in my record.