Phone: 908-923-4499 | Fax: 908-923-4011
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Star Cardiology Care, PC
403 Route 202 South, Suite 200
Flemington, NJ, 08822
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Consent
*
I agree to the privacy policy.
I allow you to share my protected health information to or answer questions from the following (this includes information regarding diagnosis, treatment, medications):
Check all that apply
Spouse
Name
Name
Phone
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Parent(s)
Name
Name
Phone
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Children
Name
Name
Phone
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Other
Name
Name
Phone
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NONE (only talk to me)
I wish to be contacted in the following manner (check all that apply)
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Cell Phone
Home Phone
Work Phone
Is it OK to leave a detailed message?
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No
Print Name
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First
Last
Signature of Patient (or Legal Guardian)
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Date
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Date Format: MM slash DD slash YYYY
Consent
*
I agree
I understand that I have the right to change this information at any time and I can request a copy of this form at any time.
This HIPAA form will be part of the Electronic Health Record (EHR)
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