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AUTHORIZATION FOR MEDICAL TREATMENT
Oklahoma Oncology and its personnel are hereby authorized to
administer any medical, diagnostic or therapeutic treatment,
including blood transfusions, as may be deemed necessary or
advisable. I have the right to consent or refuse consent, to
any proposed procedure or therapeutic course, absent emergency
or extraordinary circumstances.
DISCLOSURE OF INFORMATION
I understand that my medical records and billing information are
made and retained by Oklahoma Oncology and are accessible to office
personnel. Office personnel may use and disclose medical
information for office operations and functions and to any other
physician or health care personnel involved in my continuum of care.
Safeguards are in place to discourage improper access.
Oklahoma Oncology and its medical staff are authorized to disclose
all or part of my medical record to any insurance carrier, workers
compensation carrier, or self-insured employer group liable for any
part of Oklahoma Oncology charges and to any health care provider
who is or may become involved with my care. Oklahoma law requires
that Oklahoma Oncology advise you that the information authorized
for disclosure may include information which may be considered a
communicable or venereal disease, including, but not limited to,
Hepatitis, Syphilis, Gonorrhea, Human Immunodeficiency Virus and
Acquired Immune Deficiency Syndrome (AIDS). By signing this
agreement, you are consenting to such disclosure.
CERTIFICATION
I hereby certify that I have read each of the above statements,
have had each item explained to me to my satisfaction, and have
received a copy of this Patient Agreement. I further certify that
I am the patient or duly authorized by the patient to accept the
terms of this Patient Agreement.
A photocopy of this document has the same effect as an original.
OFFICE DIRECTORY
We may release your name and general condition to people who ask for
you by name so that your family and friends can know generally how
you are doing.
ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES
A complete description of how your medical information will be
used and disclosed by this Office Practice is in our NOTICE OF
PRIVACY PRACTICES, which you should read before signing this
agreement. A copy is posted in the Oklahoma Oncology patient
waiting area and on the Oklahoma Oncology website.
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