West Los Angeles Pulmonary Medical Group
Omar Tirmizi, MD, FCCP

Patient Consent for Use and Disclosure of Protected Health Information 

NOTE:  Under the federal privacy rules, a health care provider, health plan or healthcare clearinghouse (a “Covered Entity”) may use a patient’s protected health information (PHI) for treatment, payment and health care operations purposes (TPO) without the necessity of getting the patient’s authorization.  A Covered Entity, however, may, at its option, request a patient to provide written consent to the use of the patient’s PHI for TPO purposes.  This form may be used to obtain this consent.  This consent form covers only consent for use and disclosure of PHI for TPO, including communicating regarding PHI by certain means (e.g., voice mail, email, etc.).  

Patient:_______________________________________________               Soc. Sec. No.___________________________
Address___________________________________________________________________________________________
Date of Birth__________________	           Home/Cell #_____________________        Wk. Phone____________________

The undersigned (referred to as “I” or “me”) hereby gives consent for Omar Tirmizi, MD to use and disclose Protected Health Information (PHI) about the Patient named above to carry out treatment, payment and healthcare operations (TPO).  

Omar Tirmizi, MD’s Notice of Privacy Practices provides a more complete description of these uses and disclosures.  I agree that I have the right to review the Notice of Privacy Practices prior to signing this consent, and I acknowledge that I have done so.  Omar Tirmizi, MD reserves the right to revise its Notice of Privacy Practices at anytime.  A revised Notice of Privacy Practices may be obtained by forwarding a written request to Omar Tirmizi, MD’s Privacy Official at, Omar Tirmizi, MD 2080 Century Park East, Suite 1006 Los Angeles, CA 90067-2013.

With this consent Dr Tirmizi or his representative may call my Home___ Cell ___ Work or email ____: to remind me of appointments, insurance issues, lab results, and or issues pertaining to my health. 

I understand that I have the right to request that Omar Tirmizi, MD restrict how it uses or discloses the Patient’s PHI to carry out TPO.  However, I understand that Omar Tirmizi, MD is not required to agree to the requested restrictions, but if it does, it is bound by such agreement.  

By signing this form, I am consenting to Omar Tirmizi, MD’s use and disclosure of the Patient’s PHI to carry out TPO. 

I understand that I may revoke this consent in writing except to the extent that Omar Tirmizi, MD has already made disclosures in reliance upon it.  If I do not sign this consent, or if I later revoke it, Omar Tirmizi, MD may decline to provide treatment to the Patient.
	
_______________________________________________					______________
Signature of Patient										Date

OR 
_
__________________________________________________					______________
Signature of Parent/Legal Guardian/Personal Representative of Patient					Date

Name:_____________________________________________________ 			relationship:_____________