[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-388397-105":3,"detail-sidebar-cat-0-en-105":81,"doc-detail-388397-en":131},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","cpc-consent-and-phi-form-2022","CPC Consent and PHI Form - 2022","","CPC Consent and PHI Form (2022) captures a patient’s authorization to discuss and share protected health information with named individuals, and to permit Commonwealth Primary Care (CPC) to use and disclose PHI for treatment, payment, and healthcare operations. The form explains how health records are used to plan care, support communication among providers, assist billing, and allow verification by payers. It also covers privacy notice review, the ability to request confidential communications, limits on agreeing to restrictions, and communication by phone, mail, email, or text. It includes insurance authorization and financial responsibility terms.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/document/","Document",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/document/healthcare/","Healthcare",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/document/cpc-consent-and-phi-form-2022/388397/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/cpc-consent-and-phi-form-2022/388397.png","ImageObject",300,407,{"name":42,"@type":43},"Bintang","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-30","2026-09-25",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",11,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What does the form authorize regarding protected health information (PHI)?","Question",{"text":63,"@type":64},"The patient authorizes CPC and its agents to use and disclose PHI to carry out treatment, payment, and healthcare operations. It also allows PHI release to the individuals the patient lists for permission to discuss PHI.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Can the patient request restrictions or confidential communications?",{"text":68,"@type":64},"Yes. The patient may request how PHI is used or disclosed for treatment, payment, or operations, and may request confidential communications by alternative means or locations in writing. CPC is not required to agree to all requested restrictions.",{"name":70,"@type":61,"acceptedAnswer":71},"What financial terms and collection responsibilities are included?",{"text":72,"@type":64},"The patient is financially responsible for all charges, including uncovered amounts. If an outstanding balance exceeds 90 days, CPC may charge a late fee and refer the account for collection, with collection fees and attorney costs described in the form.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},388397,1791097470,{"code":4,"msg":82,"data":83},"success",[84,88,92,96,101,106,110,115,120,123,127],{"id":22,"doc_module":4,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Story & Novel",90,"story-novel",{"id":26,"doc_module":4,"doc_module_name":25,"category_name":89,"show_sort_weight":90,"slug":91},"Literature",80,"literature",{"id":33,"doc_module":4,"doc_module_name":25,"category_name":93,"show_sort_weight":94,"slug":95},"Exam",70,"exam",{"id":97,"doc_module":4,"doc_module_name":25,"category_name":98,"show_sort_weight":99,"slug":100},5,"Comic",60,"comic",{"id":102,"doc_module":4,"doc_module_name":25,"category_name":103,"show_sort_weight":104,"slug":105},6,"Technology",50,"technology",{"id":107,"doc_module":4,"doc_module_name":25,"category_name":29,"show_sort_weight":108,"slug":109},7,40,"healthcare",{"id":111,"doc_module":4,"doc_module_name":25,"category_name":112,"show_sort_weight":113,"slug":114},8,"Research & Report",30,"research-report",{"id":116,"doc_module":4,"doc_module_name":25,"category_name":117,"show_sort_weight":118,"slug":119},9,"Religion & Spirituality",20,"religion-spirituality",{"id":118,"doc_module":4,"doc_module_name":25,"category_name":121,"show_sort_weight":118,"slug":122},"World Cup","world-cup",{"id":124,"doc_module":4,"doc_module_name":25,"category_name":125,"show_sort_weight":124,"slug":126},10,"Lifestyle","lifestyle",{"id":128,"doc_module":4,"doc_module_name":25,"category_name":129,"show_sort_weight":97,"slug":130},19,"General","general",{"code":4,"msg":82,"data":132},{"doc_id":79,"user_id":133,"nickname":42,"user_avatar":134,"doc_module":4,"category_id":107,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":140,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":12,"update_tm":144,"read_time":97,"preview_page_count":4},962085564381,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","Name:   Date of birth:    \nLast First Middle Suffix  \nPermission to Discuss PHI: I authorize CPC and its agents to release my protected health information to the following individuals:  \nName Relationship Phone Number  \n_____________________________ _________________________ _______________________  \n_____________________________ _________________________ _______________________  \n_____________________________ _________________________ _______________________  \n_____________________________ _________________________ _______________________  \nConsent to Treatment: I understand that as part of my healthcare, Commonwealth Primary Care (CPC) originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care and treatment. I also understand this information serves as:  \n• A basis for planning my care and treatment  \n• A means of communication among the many health professionals who contribute to my care  \n• A source of information for applying my diagnosis and surgical information to my bill  \n• A means by which a third party payer can verify that services billed were actually provided  \n• And a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.  \nI understand and have been provided with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand CPC reserves the right to change their notice and practices, a current version of which is available on the CPC Web site ([http://www.cpcva.com](http://www.cpcva.com)) . I also understand that I have the right to restrict how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that CPC is not required to agree to the restrictions requested. I have the right to request to receive confidential communications of protected health information by alternative means or at alternative locations. Such request must be in writing and CPC will accommodate any reasonable requests.  \nBy providing a cell number, I agree that CPC, its affiliates, or those acting on their behalf, may call or text using an automatic telephone dialing system and/or a prerecorded message. With this consent, CPC may call my home, cellular telephone, or other designated location and leave a message on voice mail or in person in reference to any items that assist CPC in carrying out treatment, payment, and operations activities, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results.  \nWith this consent, Commonwealth Primary Care may mail to my home or other designated location any items that assist CPC in carrying out treatment, payment, and operations activities , such as appointment remindersand other correspondence as long as they are marked Personal and Confidential.  \nWith this consent, Commonwealth Primary Care may e-mail or text me appointment reminders and patient statements.  \nBy signing this form, I am consenting to Commonwealth Primary Care’s use and disclose my PHI to carry out my treatment, payment, and operations activities.  \nI may revoke my consent in writing except to the extent that CPC has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Commonwealth Primary Care may decline to provide treatment to me.  \nInsurance Authorization: I authorize the release of any medical information to any insurance company, Medigap Insurance, third party administrator, or other payer that is necessary to process the claim and request payment of benefits either to myself or to CPC. I authorize CPC and its agents to release medical information contained in my medical record to any insurance companies, federal programs or state programs with which I am insured o","cbCaiqO9qIFYFdFV","https://ap.wps.com/l/cbCaiqO9qIFYFdFV","pdf",130247,"English","# Permission to Discuss PHI\n# Consent to Treatment\n# Communication Authorization\n# Revocation and Refusal of Treatment\n# Insurance Authorization\n# Financial Responsibility\n# Assignment of Benefits\n# Patient Attestation and Signature","[{\"question\":\"What does the form authorize regarding protected health information (PHI)?\",\"answer\":\"The patient authorizes CPC and its agents to use and disclose PHI to carry out treatment, payment, and healthcare operations. It also allows PHI release to the individuals the patient lists for permission to discuss PHI.\"},{\"question\":\"Can the patient request restrictions or confidential communications?\",\"answer\":\"Yes. The patient may request how PHI is used or disclosed for treatment, payment, or operations, and may request confidential communications by alternative means or locations in writing. CPC is not required to agree to all requested restrictions.\"},{\"question\":\"What financial terms and collection responsibilities are included?\",\"answer\":\"The patient is financially responsible for all charges, including uncovered amounts. If an outstanding balance exceeds 90 days, CPC may charge a late fee and refer the account for collection, with collection fees and attorney costs described in the form.\"}]","CPC Consent and PHI Form - 2022 | PDF",1790302743]