Patient Consent for Use & Disclosure of Individually Identifiable Heath Information

With my consent, Kauai Osteopathic, Inc may use and disclose individually identifiable health information (IIHI) about me to carry out treatment, payment, healthcare operations (TPO), education and training, appointment reminders, treatment alternatives, and health related benefits and services. Please refer to Kauai Osteopathic, Inc.'s Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Kauai Osteopathic, Inc 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 Kauai Osteopathic, Inc.'s Privacy Officer at P.O. Box 817, Koloa, HI 96756.

With my consent, Kauai Osteopathic, Inc 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, education and training, treatment alternatives, and health related benefits and services, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others.

With my consent, Kauai Osteopathic, Inc may mail to my home or other designated location any items that assist the practice in carrying out TPO, educational training, treatment alternatives, and health related benefits and services, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.

I have the right to request that Kauai Osteopathic, Inc restrict how it uses or discloses my IIHI to carry out TPO, educational training, treatment alternatives, and health related benefits and services. 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 Kauai Osteopathic, Inc.'s use and disclosure of my IIHI to carry out TPO, educational training, treatment alternatives, appointment reminders, and health related benefits and services.

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, Kauai Osteopathic, Inc may decline to provide treatment to me.

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Signature of Patient or Legal Guardian Print name of Patient of Legal Guardian


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Patient's Name Date

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