OF PROTECTED HEALTH INFORMATION By signing this form, I hereby give my consent for Daniel K. Hellerstein MD PA to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). (Daniel K. Hellerstein MD PA's Notice of Privacy Practices provides 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. Daniel K. Hellerstein MD PA 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 Daniel K. Hellerstein MD PA Privacy Official at Suite 5100 1411 North Flagler Drive West Palm Beach, Florida 33401. With this consent, Daniel K. Hellerstein MD PA may call my home, cell or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others. With this consent, Daniel K. Hellerstein MD PA may mail to my home or other alternative 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 Daniel K. Hellerstein MD PA restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Daniel K. Hellerstein MD PA may decline to provide treatment to me.
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DANIEL K. HELLERSTEIN, M.D., P.A.
1411 North Flagler Drive
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