Hill Center for Dermatology, PC
17560 S. Golden Road, Suite 100
Golden, CO 80401
303-526-2800

CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS

NAME:________________________________________

DATE OF BIRTH:__________________

I understand that Hill Center for Dermatology, PC originates and maintains health records describing my personal and family health history, symptoms, examinations, test results, diagnosis, treatment and plans for future care.

I understand this information serves as:

• A basis for planning my care and treatment.
• A means of communication with healthcare professionals who contribute to or participate with my care.
• A source to provide diagnosis and treatment to my insurance company and/or third party payor for billing purposes.
• A means by which my insurance company and/or third party payor can verify services.
• A tool for ensuring quality of care and competency of healthcare professionals.
  

I understand I have the right:

• To restrict how my healthcare information is used or disclosed.

All requests for restrictions must be in writing and given to your provider.

Please contact our office at 303-526-1117 if you have any questions. Thank you.