Consent for Care
Last Updated: May 27 2020

Consent and Understanding
This consent is required by the Health Insurance Portability and Accountability Act of 1996 to inform you of your rights for privacy with respect to your health care information.

Consent Related to Privacy Notice
I have had a chance to review the Practice Privacy Notice as part of this registration process. I understand that the terms of the Privacy Notice may change and I may obtain these revised notices by contacting the practice by phone or in writing, digital or physical. I understand I have the right to request how my protected health information (PHI) has been disclosed. I also have the right to restrict how this information is disclosed, but Prairie Health is not required to agree to my restrictions. If it does agree to my restrictions on PHI use, it is bound by that agreement.

Consent Related to Telehealth
I have had a chance to review the Telehealth Consent Notice as part of this registration process. I understand that the terms of the Telehealth Consent Notice may change and I may obtain these revised notices by contacting the practice by phone or in writing, digital or physical.

Consent for Care
I authorize Prairie Health’s third party physician, and any employee working under the direction of the physician, to provide medical care for me. This medical care may include services and supplies related to my health and may include (but not limited to) preventative, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body and the sale or dispensing of drugs, devices, equipment or other items required and in accordance with a prescription. This consent includes contact and discussion with other health care professionals for care and treatment.

Financial Policy
I understand that I am liable for all costs associated with Prairie Health’s service. We do not work with insurance carriers, and the patient/responsible party assumes responsibility to ensure that the financial obligation is fulfilled for the health care services received.

741-741

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