City of Greensboro Personnel Policy Manual

City of Greensboro Personnel Policy Manuał

Appendix Document: Medical Consent Form and HIPAA Statement Effective Date: 04-01-2007 Revisions: 1 Pages: 1 Policies Referenced: K-1 Notice of Privacy Practice and Consent to Medical Treatment Release of Information This notice describes how health information about you may be used and disclosed and how you can get access to your individually identifiable health information. Please review it carefully. On April 14, 2003, the HIPAA Rules became effective. These standards relate to the privacy of individual health information and how it may be used. Information involving “return to work” issues such as work restrictions that may affect your job will be shared with your supervisor or manager, but medical treatment provided during your illness and recovery will not be shared unless you provide a signed authorization for information to be provided to a specific individual. A “Protected Medical Records Policy” is posted in Medical Services. If you have questions regarding this, please call (336) 373-2412. Initial Statement I have reviewed the above Privacy Rules Document.

I authorize the release of any medical or other information necessary to provide treatment, carry out healthcare operations, or process a health insurance or third party payer claim. Consent to Treatment I consent to any medical or surgical treatment under the general or special instructions of the physician. I also certify that no guarantee or assurance has been made to me in regards to the results which may be obtained.

Signature: Please print name: Date:

Table of Contents A B C D E F H I J K L List of Appendices G

Appendix

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