Mid Island Internal Medicine
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Disclosure

With my Consent, Mid island Internal Medicine, PLLC may use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operation (TPO). Please refer to Mid Island Internal Medicine's notice of Privacy for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy practices prior to signing this consent. Mid Island Internal Medicine, PLLC reserves the right to revise its Notice of Privacy at anytime. A revised notice of Privacy Practices may be obtained by fowarding a written request to Anderea Nomberg, MD, Privacy Officer at 709 hawkins Avenue, Ronkonkoma, NY 11779.

With my consent, Mid Island Internal Medicine, PLLC may call my home or other designated locations and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any calls pertaining to my clinical care, including laboratory and radiology results, among others. Normal lab values and non-sensitive information may be left with immediate family members or on your voice mail. However, we will make every attempt to discuss abnormal results and non-sensitive information only with you, the patient. As Always, you are welcome to contact us at any time in reference to any aspect of your care.

With my consent, Mid Island Internal Medicine, PLLC may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards, and sympathy cards may be sent, however, without being marked personal and confidential.

With my consent, Mid Island Internal Medicine, PLLC may e-mail to my home or other designated location with any items that  assist the practive in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Mid Island Internal Medicine, PLLC restrict how it uses or discloses my PHI to carry out TPO.

However, the practice is not required to agree to my requested restriction, but if it does it is bound by this agreement.

By agreeing to this form, I am consenting to Mid Island Internal Medicine, PLLC's use and disclosure of my PHI to carry out TPO.

Disclosures in reliance upon my prior consent. If I do not agree to this consent, Mid Island Internal Medicine, PLLC may decline to provide treatment to me.

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