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Patient HIPAA Consent to the
Use and Disclosure of Health Information for Treatment, Payment,
or Healthcare Operations
The physicians of Syracuse
Anesthesia and Pain Management, PLLC
("Anesthesia Group") provide
anesthesia services at Specialty Surgery Center of CNY ("Surgery
Center"). By signing this consent form, you agree to allow both
Anesthesia Group and the Surgery Center to use your individually
identifiable health information for the purposes described
below. You also acknowledge that you have received the notice
that describes the privacy practices of both Anesthesia Group
and the Surgery Center. The Surgery Center and Anesthesia Group
have developed a joint notice of their privacy practices and are
using this joint consent form in order to simplify the
administrative process for patients. However, Anesthesia Group
and the Surgery Center are separate legal entities. They are
each separately required to comply with state and federal law.
They must each comply with the notice and this consent form. The
Surgery Center and Anesthesia Group are not responsible for the
other’s failure to comply with the notice or this consent form.
I understand that as part of my
healthcare, the Surgery Center and Anesthesia Group create and
maintain health records describing my health history. I
understand that the surgery center and Anesthesia Group may use
this information as:
1. a basis for planning my
care and treatment;
2. a means of communication
among many health professionals who contribute to my
care;
3. a means by which
third-party payors can verify that services billed were
actually provided; and
4. a tool for routine health
care operations such as assessing quality and reviewing
the competence of health care professionals.
I hereby consent to the Surgery
Center’s and Anesthesia Group’s use and disclosure of my
individually identifiable health information for the purposes
listed above and other purposes relating to my treatment, the
payment of my health care, and other health care operations of
the Surgery Center and Anesthesia Group. In addition, I
acknowledge that I received on the date indicated below a copy
of the Specialty Surgery Center of CNY/ Syracuse Anesthesia and
Pain Service, PLLC Notice of Privacy Practices, which describes
the obligations of the Surgery Center and Anesthesia Group
regarding their use and disclosure of my individually
identifiable health information and my rights regarding this
information. I also understand that the Surgery Center and
Anesthesia Group reserve the right to change their notice and
practices. If the Surgery Center and Anesthesia Group change the
notice, I can obtain a revised copy by asking the administrator
of the Surgery Center. I understand that I have the right to
request restrictions as to how my health information may be used
or disclosed to carry out treatment, payment, or other
healthcare operations and that the Surgery Center and Anesthesia
Group are not required to agree to the restrictions requested.
If the Surgery Center or Anesthesia Group do agree to such
restrictions, however, they must comply with such restrictions.
_____ I request the following
restrictions to the use or disclosure of my health information.
(Effective Date of Notice: April 14,
2003)
_____________________________________
Date:_________
Signature of patient or patient’s representative
Printed name of patient’s
representative:_________________________________________
Relationship to
patient:_______________________________________________
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