Filling out this necessary form helps to save you time on the day of your visit. You can fill out all necessary fields and hit SUBMIT when you’re done, or you can click the link below to download the form to your computer, fill it out by hand, and either fax, mail, or bring the form with you on your appointment day.

With my permission, Dr. John Siegal may use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). Please refer to Dr. John Siegal’s Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Dr. John Siegal reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Practices may be obtained by forwarding a written request to the Privacy Officer.

With my permission, the office of Dr. John Siegal may call my home or other designated locations and leave a message on voicemail or in person in reference to any items that assist the practices on carrying out TPO, such as appointments reminders, insurance items and any call pertaining to my clinical care, including results among others.

With my permission, the office of Dr. John Siegal may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and or Confidential. With my permission, the office of Dr. John Siegal may email to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Dr. John Siegal restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this, I am allowing Dr. John Siegal to use and disclose my PHI for TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.