Patient Care Forms

In our patient care division, your convenience and comfort are our first concerns at all times. Our simple registration forms streamline the process and ensure that your information is securely stored and accessible to our medical personnel. Managing your healthcare journey is made easier with our comprehensive forms, whether you’re scheduling an appointment, giving insurance details, or obtaining access to medical records. You can feel secure knowing that your privacy is our top priority and that our HIPAA-compliant forms take great care to protect your sensitive information. You can obtain patient care without difficulty and enhance your entire healthcare experience by using our easy-to-use forms.

HIPAA Authorization Form for BCEDD Device

Patient Information:

– Full Name: __________________________

– Date of Birth: ________________________

– Address: _____________________________

– Phone Number: _______________________

– Email Address: _______________________

Authorization:

I, [Patient’s Name], provide permission for my protected health information (PHI) to be used and disclosed in the instances listed below:

Purpose: I understand that my PHI will be used for the purpose of breast cancer screening and monitoring using the BCEDD device.

Disclosure: I give permission for my PHI to be shared with approved medical professionals who are treating and caring for me.

Use of Data: I agree that my PHI may be used for quality improvement, research, and data analysis pertaining to the identification and prevention of breast cancer.

Confidentiality: I am aware that my personal health information will be kept private and not shared with any unauthorized individuals.

Retention: I understand that my PHI might be kept for the length of time specified in this authorization or as long as needed to fulfill legal requirements.

Expiration and Revocation:

– This authorization will expire [1 year from today’s date].

– I understand that I have the right to revoke this authorization at any time by submitting a written request to [BCEDD.support@gmail.com]

Acknowledgment:

I have reviewed this HIPAA Authorization Form and I understand its contents. I agree to the use and transmission of my protected health information as indicated below, and I sign below to confirm this.

Patient Signature: ________________________

Date: __________________________