Ironwood Physicians
Ironwood Cancer & Research Centers Ironwood Radiology
Patient Consent for Use and Disclosure of Protected Health Information
With your consent, Ironwood Physicians may use and disclose protected health information (PHI) about you to carry out treatment, payment and health care options (HCO). Please refer to our Notice of Privacy Practices for a more complete description of such uses and disclosures. You have the right to review our Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to our Privacy Officer at P0 Box 6423, Chandler, AZ 85246
With your consent, Ironwood Physicians may mail to your home or office and leave a message in reference at any items that assist the practice in carrying out HCO such as appointment reminders, insurance items and any call pertaining to your clinical care.
With your consent, Ironwood Physicians may mail to your home or office any items that assist the practice in carrying out any HCO such as appointment reminder cards and patient statements.
You have the right to request that we restrict how we use or disclose your PHI, to carry out treatment, payment and healthcare operations. However, we are not required to agree to your requested restrictions, but if we do, we are bound to our agreement.
By signing this form, you are consenting to our use and disclosure of your PHI to carry out treatment payment and healthcare operations. This consent may be revoked in writing except to the extent that we may have already made disclosures in reliance upon your prior consent.
If you decline to sign this consents we may decline to provide treatment for you.