Patient care and service will be provided over the course of two years. Program staff will schedule your visits in advance to best fit your schedule. If at any time you have questions about the program, you can contact study staff at (225) 763-2789.
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TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).
This consent provides Pennington Biomedical Research Center with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other affiliated office. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.
I voluntarily request a physician, and/or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or their designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. . I am aware that Pennington Biomedical Research Center is affiliated with teaching programs, and as a result, medical students, residents, nursing students, and other medical career students may be involved in my care. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.
Protected Health Information
I understand that the information contained in my medical records is confidential, however, I give permission to this facility and care team to release any and all protected health information (PHI) to healthcare professionals and facilities involved in my treatment and follow up care. This sharing, if necessary, will only be done when a treatment relationship is in effect and will be done in a secure and confidential manner and in accordance with data sharing systems and agreements of the organizations. I understand that I may request that Pennington Biomedical Research Center not share my information, and that in order to do so I must request and complete an opt-out form. I understand that doing so may delay communications of information between providers involved in my care. I understand that Pennington Biomedical Research Center may still share my health information in emergency treatment situations.
I understand that Pennington Biomedical Research Center participates in efforts with the Louisiana Office of Public Health to prevent and control infectious diseases such as HIV, measles, Tuberculosis, the flu, and others). Pennington Biomedical Research Center may share PHI with the Office of Public Health as necessary or required by law. I understand that this facility reports immunization information to the Office of Public Health if an immunization is received.
I give permission to release any and all PHI to my insurance company/provider requesting the information on my behalf for purposes of payment, claims, appear, or reimbursement of expenses for medical treatment.
Financial Agreement
I assign to Pennington Biomedical Research Center all benefits covering medical expenses. I certify that the information given for the Medically Indigent (Free Care) and/or any application for Medicaid (Title XIX) or Medicare (XVIII) is true and correct. I further agree that, should the amount paid be insufficient to cover the entire medical expense, I will be responsible for payment of any differences. I understand that my physician(s) will send me a separate bill for their services, and that this authorization and assignment also applies to them. If I do not want my insurance company billed, I realize that I must put that request in writing. I understand that if Pennington Biomedical Research Center is not a provider for my health insurance that I can be billed for services.
Patient Rights and Responsibilities
I understand that a copy of the Patient Rights and Responsibilities is available upon request. I understand that I will receive these on my first visit to Pennington Biomedical Research Center and that on return, this Notice is available on request.
Consent for Photo ID
I consent for my photo ID to be stored in my electronic and physical medical record to protect my safety and identity. If I do not want my photo taken, I must notify the Pennington Biomedical Research Center staff requesting the photo.
Consent to Receive Automated Phone Calls
I understand that if I provide my wireless/cellular phone number to Pennington Biomedical Research Center, that I may receive automated calls/texts from, or those acting on the behalf of, Pennington Biomedical Research Center. I understand that the primary purpose of these communications is to remind me of upcoming appointments or for treatment related information. All standard charges for calls/texts apply. I understand I may opt out of automated calls or texts at any time, but I must notify Pennington Biomedical Research Center if I do so. Agreeing to receive automated calls and texts is not a requirement for treatment.
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Authority to Release Protected Health Information:
I hereby authorize Pennington Biomedical Research Center to release the information identified in this authorization form from my medical records and provide such information to the recipient listed below.
Authority to Request Protected Health Information:
I hereby authorize the recipient listed below to release the information identified in this authorization form from my medical records and provide such information to:
Pennington Biomedical Research Center
6400 Perkins Rd.
Baton Rouge, LA 70808
Attn: Medical Records
Drug and/or Alcohol Abuse, and/or Psychiatric, and/or HIV/AIDS Records Release
I understand if my medical or billing record contains information in reference to drug and/or alcohol abuse, psychiatric care, sexually transmitted disease, hepatitis B or C testing, and/or other sensitive information, I agree to its release.
I understand if my medical or billing record contains information in reference to HIV/AIDS (Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome) testing and/or treatment I agree to its release.
Type of information to be released:
Complete health record, History & Physical Exam, Laboratory Test Results, Diagnosis & Treatment Codes, Consultation Reports, Discharge Summary, Progress noted.
Purpose of the Requested Disclosure of Protected Health Information:
I am authhorizing the release of my Protected Health Information for provider review.
Right to Revoke Authorization:
Except to the extent that action has already been taken in reliance on this authorization, the authorization may be revoked at any time by submitting a written notice to Medical Records Coordinator at Pennington Biomedical Research Center, 6400 Perkins Road, Baton Rouge, LA 70808. Unless revoked, this authorization will expire two years from date of this document.
Re-disclosure:
I understand the information disclosed by this authorization may be subject to re-disclosure by the recipient and no longer be protected by the Health Insurance Portability and Accountability Act of 1996.
Signature of Subject or Personal Representative Who May Request Disclosure:
I understand that I do not have to sign this authorization, and my treatment or payment for services will not be denied if I do not sign this form. However, if health care services are being provided to me for the purpose of providing information to a third-party (e.g. fitness-for-work test), I understand that services may be denied if I do not authorize the release of information related to such health care services to the third-party. I can inspect or copy the protected health information to be used or disclosed. I hereby release and discharge the Provider named above who is duly authorized to release the records and Pennington Biomedical Research Center and its officers, directors, and employees of any liability and the undersigned will hold them harmless of complying with this Authorization.
]]>Welcome to our clinic! Please complete the following paperwork to enroll in the Pennington Diabetes Clinic.
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