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407 Appendix
City of Greensboro Personnel Policy Manuał
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Appendix Document:
Medical Consent Form and HIPPA Statement
Effective Date: 4-1-07
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 or contact Human Resources (336) 373-2618.
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: