Wimahl Family Clinic

2120 Exchange Street, Suite 209 Astoria, OR 97103 Phone: 503-338-2993 Fax: 503-338-2996

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Scott Ashley, MD

Alexander Gloria, MD

Adriane Tuttle, NP

This does not limit your access to other providers within Wimahl Family Clinic.

Consent Form

By signing and initialing this form, I understand that as part of my health care, Wimahl Family Clinic originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:

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A basis for planning my care and treatment.

A means of communication among the health professionals who contribute to my care.

A source of information for applying my diabnosis and surgical information to my bill.

A means by which a third party payer can verify that services billed were actually provided.

A tool for routine health care operations, such as assessing quality, and also reviewing the competence of health care professionals.

I understand and have been provided with a ?Notice of Privacy Practices? that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

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The right to review the notice prior to signing this consent.

The right to object to the use of my health information for directory purposes.

The right to request restrictions as to how my health information may be used or disclosed to carry out treatmetn, payment or health care operations.

Patient Initials *

I understand that Wimahl Family Clinic is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

Patient Initials *

I further understand that Wimahl Family Clinic reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. I may obtain a revised Notice of Privacy Practices by request.

Patient Initials *

I fully understand and accept the terms of this consent.

Patient's Signature (name typed here is equivalent to a signature): *

Date of Birth *

Date Signed *

Wimahl Family Clinic

Available Forms

Consent Form - Adult

Wimahl Family Clinic

Consent Form