PATIENT CONSENT FORM

Drs Kauffman and Partners Inc takes the privacy of persons seriously, and is therefore committed to ensuring that personal information in its possession or under its control is secure.

Please note that below form is only relevant should you require Dr Kauffman and Partners to either RETRIEVE OR SHARE your study information (report/images) with ANOTHER practice which is not currently part of your Circle of Care.

Please complete the below Patient Image Sharing/Retrieving Consent form

I, the undersigned Patient or parent/legal guardian of the Patient (as applicable), hereby give my consent for Dr Kauffman and Partners Radiologist to Send or Retrieve my / the patient’s personal medical information (images and reports) to or from the below mentioned third parties in connection with my care.

Statement of Consent:

1.I understand that the information is about me, or the patient of whom I am the parent or legal guardian (of a child, incapacitated – or elderly person)

2. I understand that the information will be sent to or retrieved from the below-mentioned third parties, as requested.

3. My consent is voluntary, and I understand that I can withdraw it at any time.

4. I understand that the information will be transferred electronically.

STEP 1:

Complete the below fields with the relevant information.

Patients Name and Surname *

Patients ID Number *

Date of birth *

Phone *

Please use the phone number where we can contact you to verify the information (if required).

Email *

Please use the email to which you would like to the consent to be shared to.

Please select if applicable

I am a Parent, or legal guardian of the patient

STEP 2:

Please select one of the tick boxes below to either RETRIEVE your reports/images from another practice or SEND your reports/images (which was done with Dr Kauffman and Partners) to another practice.

RETRIEVE FROM (Our team will get your images/report from another practice for your doctor to review in our system)

SEND TO (Our team will send your images/report to another practice/organisation/doctor)

Study Requested *

Date of Study *

STEP 3:

Please complete the Third Party information so we will know where to either retrieve from or send your information.

Disclaimer:
By completing this document, I am allowing the third party (listed above) access to confidential patient information, including images and reports. By giving my consent, I indemnify Dr Kauffman and Partners for any consequences arising from the unauthorized access of my/the patient’s images, reports and/or personal information.