HIPAA Privacy Form - Ste Genevieve County Memorial Hospital - stegenevievehospital 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by answering the appointment reminder question. Select 'Yes' or 'No' for whether you would like to receive a call reminding you of your appointment.
3. Proceed to the next questions regarding message permissions. Indicate your preferences for receiving messages on your answering machine and if results can be left there.
4. Fill in your work number if you consent to receive test results at work, and answer whether you authorize discussions about your health information with family members.
5. If applicable, list the names, relationships, and phone numbers of any family members authorized to discuss your health information.
6. Review the consent section carefully. Confirm that you understand the use of your protected health information for treatment, payment, and healthcare services.
7. Finally, print your name, sign as the patient or legal guardian, indicate your relationship to the patient if necessary, and date the form.

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