Weeks Premature
(put "0" if not premature)

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

List others assisting with completion of the questionnaire

Patient Consent for Use and Disclosure 

of Protected Health Information

I hereby give my consent for Zarminali Pediatrics to use and disclose

protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). 

(The Notice of Privacy Practices provided by Zarminali Pediatrics describes such uses and disclosures more completely.) 

I have the right to review the Notice of Privacy Practices prior to signing this consent. 

Zarminali Pediatrics reserves the right to revise its Notice of Privacy Practices

at any time. A revised Notice of Privacy Practices may be obtained by forwarding a 

written request to Kyle Butler-Myers at 106 Irving St NW Suite 2300, Washington, DC 20010.

With this consent, Zarminali Pediatrics may call my home or other alternative location 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 test results, among others. 

With this consent, Zarminali Pediatrics may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.

With this consent, Zarminali Pediatrics may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Zarminali Pediatrics restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. 

By signing this form, I am consenting to allow Zarminali Pediatrics to use and disclose my PHI to carry out TPO. 

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Zarminali Pediatrics may decline to provide treatment to me.

Note: By clicking "Submit", you are agreeing to both our Family Access End User License Agreement and any other consent or authorization information outlined on this page.