FOR TREATMENT
I, the undersigned, have voluntarily presented to Ibn Sina Foundation (ISF) for medical/or dental
evaluation, diagnosis, and/or treatment. I consent and authorize my provider(s) or his or her
designee(s) to provide diagnostic and therapeutic treatment, which may be necessary or advisable in
their professional judgment. By signing this consent form, I do not waive my right to refuse
recommended tests or treatment(s).
HIV CONSENT
I understand that during the time of treatment, health care workers may be exposed to the patients’
blood and/or body fluids increasing their risk of contracting Hepatitis B, Hepatitis C, and/or HIV.
As part of my treatment, it may be requested that I be tested to determine if I have/had previous
contact with the HIV, Hepatitis B, and Hepatitis C. This might be done as part of a diagnostic test
or for hospital/or clinic infection control reasons. I understand the need for testing for these
diseases and I agree to such testing of myself to promote the health and welfare of the health care
worker.
RELEASE OF INFORMATION
I hereby authorize the ISF to use or disclose my protected health information acquired during my
examination and treatment to any authorized agent for the purposes of healthcare, treatment, and
payment as described in the Notice of Privacy Practices. I authorize the release of medical
information to my insurers as necessary for determination and payment of benefits; to healthcare
providers involved in my care; to utilization review and professional standards review
organizations, companies, and community resources that assist me with my healthcare needs. ISF may
provide vaccination information to the state vaccine registry via electronic integration. I
understand that my consent is not needed if the law requires ISF to report some aspect of my
protected health information to a government agency (for example, suspected abuse, communicable
disease and potential bodily harm to myself or others). I understand and acknowledge that ISF
participates in an electronic medical record exchange program, and that if I seek treatment from
other healthcare facilities or providers participating in this exchange program, my health
information may be shared between ISF and those other facilities or providers for purposes of the
delivery of care and services to me. I understand that my medication history will be retrieved for
the last 12 months including medications I have filled through my prescription drug plan.
MEDICARE/MEDICAID PATIENTS
I authorize to release medical information about me to social security administration or its
intermediaries for my Medicare/Medicaid/ Medigap claims. I assign the benefits payable for services
to ISF.
NOTICE OF PRIVACY
HIPPA ACKNOWLEDGMENT: I understand that under the Health Insurance Portability and Accountability Act
of 1996 (HIPAA), I have certain patient rights regarding my protected health information. I
understand that I have the right to review ISF Notice of Privacy Practices/Patients’ Rights and the
most recent copy is available upon request. I understand that I may request restrictions be put on
the use of my information, and to revoke my consent later. I understand that if I withhold consent
for the use of my information for the purpose of treatment, payment or operations, ISF may refuse to
undertake my care.
TREATMENT BY TRAINEES AND RESEARCH:
I understand that ISF takes part in education of medical/dental trainees and as such, services may be
performed by individuals selected and deemed qualified by the attending physicians. Further,
treatment and medical records may be reviewed by approved student and attending physicians for
teaching, studies and research purposes. Information identifying patients will not be published
without prior patient consent. I authorize residents /students to observe, cooperate, and
participate in my care. Further, I agree to participate and/or be contacted to participate in
clinical research/advanced clinical care that would be beneficial for me and/or for other patients
with a similar diagnosis.
GHH CONSENT:
ISF participates in Greater Houston Healthconnect (GHH), a non-profit organization that provides a
secured electronic network for Healthconnect participants, including doctors’ offices, hospitals,
labs, pharmacies, radiology centers and payers of health claims such as health insurers to share
your protected health information. By signing this Authorization, you agree that GHH and its current
and future participants may use and disclose your protected health information electronically
through GHH for the limited purposes of treatment, payment, and health care operations. This
authorization remains in effect unless and until you revoke it. You can revoke this authorization at
any time by giving written notice to any healthcare provider who participates in GHH.
RESEARCH PARTICIPATION:
Ibn Sina community clinics participates in research studies which can involve proven or experimental treatments. 1 agree to participate and/or be contacted to participate in clinical research/advanced clinical care that would be beneficial for me and/or for other patients with a similar diagnosis. Information identifying patients will not be published without prior patient consent. I authorize residents /students to observe, cooperate, and participate in my care.
