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Telehealth Consent Form


Patient Enrollment and Intake
For a telehealth appointment, call 601-815-2020.

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Consent for Treatment, Authorization to Release Medical Information, Assignment of Insurance Benefits for Hospitals and Physicians, and Patient Self Determination Act Checklist

AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize University of Mississippi Health Care or my attending physician or any contractor on behalf of University of Mississippi Health Care to release or disclose information from my hospital medical record pertaining to this hospitalization, in accordance with the policies of this hospital, to insurance companies and/or hospital benefits programs as needed to process this claim.

AUTHORIZATION TO PAY INSURANCE BENEFITS: I hereby assign payment directly to University of Mississippi Health Care and/or to my physicians, benefits payable to me but not to exceed the hospitals or physicians regular charges for this period of hospitalization. I understand that I am financially responsible for charges not covered by this authorization.

FINANCIAL AGREEMENT: For services rendered, I, the undersigned, agree to pay all professional and hospital charges not covered by insurance. I also agree to pay all attorney and/or collection fees necessary for the collection of payment.

MEDICAID PATIENT CERTIFICATION: I certify that I am a recipient of the Medicaid Title XIX program and request that payment of authorized benefits be made on my behalf. I authorize any holder of medical or other information about me to make available to the Division of Medicaid any requested information concerning medical, insurance and financial records related to my hospitalization. I assign the benefits payable for services rendered to the physicians or organization furnishing such services.

STATEMENT TO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDER, PHYSICIAN, AND PATIENT: I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for services rendered to the physicians or organization furnishing such services.

NOTICE TO BENEFICIARIES OF COINSURANCE LIABILITY: When services are provided in hospital departments, the beneficiary will receive a hospital bill and will receive bill(s) from any physician providing professional services. The beneficiary/guarantor will be responsible for coinsurance amounts relating to services billed by the hospital and for coinsurance amounts relating to services billed separately by the physician(s). When services are provided in private physician offices or other non-hospital clinics, the beneficiary is responsible only for coinsurance amounts relating to charges billed by the physicians.

CONSENT FOR TREATMENT: The undersigned authorizes physicians and University of Mississippi Health Care to furnish medical and surgical treatment deemed appropriate including intravenous solutions, blood transfusions, local, general, and regional anesthetics, antibiotics or other drugs deemed necessary. I am aware that adverse unforeseen reactions can occur and may even result in death. I authorize the hospital and my physicians to take photographs, video, audio, or other images or recordings of me or parts of my body while under the care of the hospital for use in medical evaluation, performance improvement, education or research. I further understand that my identity will be concealed and my privacy maintained if the material is used for educational purposes.

I hereby authorize The University Hospitals and Health System and its medical staff: to preserve, use or disclose, or share for scientific or teaching purposes, including research; to use in grafts or transplants upon living person(s); or to otherwise dispose of dismembered tissue, blood, saliva, parts and the like.

RETIREMENT/DESTRUCTION OF X-RAYS: I hereby authorize University of Mississippi Health Care to follow the usual hospital practice of retiring x-ray films and any other graphic data which may be generated during patient’s hospitalization four (4) years after they are generated if a report of the findings is retained for the same period as other hospital records. Further, I hereby release and hold harmless University of Mississippi Health Care, its officers, staff and employees, from any liability connected with this procedure.

VALUABLES: The undersigned hereby releases the hospital from any responsibility due to loss or damage of any valuables that the patient may keep in his/her possession or that may be brought to him/her by other persons.

Consent for Treatment

Has the patient executed an Advance Directive?
Has the Advance Directive information been provided to the patient?
Is the Advance Directive in the patient's medical record?
Do you want to discuss Advance Health Care Directives with someone?
By checking Yes, I agree that the above information is correct.*
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Notice of Privacy Practices

Effective Date: January 1, 2015

This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

UMMC creates a record of the care and services you receive from us. We call this record your health information. We are required by federal law to keep your health information private. We are also required to provide you with this Notice so that you will know how we use and release your health information. This notice also lists the rights you have regarding your health information. We will abide by the terms of the notice. This Notice covers your care provided at UMMC sites of service.

We reserve the right to change the terms of this notice and our privacy practices at any time. Any changes will apply to the health information we already have. When we make changes to our privacy practices, we will post an updated notice in the places where you may get treatment from UMMC. You can also request a copy of this notice at any time, and you may view a copy of the notice on our web site at


Uses and Releases Relating to Treatment, Payment, or Health Care Operations (TPO) & Notice of Distinct Uses and Releases for TPO

For Treatment. For example, a doctor treating you for chest pain may need to know if you have any existing heart problems so that he/she can make an informed decision concerning your treatment. Additionally, we will/may contact you to (1) remind you of your appointment by calling or mailing a postcard; or (2) discuss treatment alternatives or other health related benefits that may be of interest to you as a patient.

To Obtain Payment for Treatment. For example, we will release some of your health information to your health insurance company in order to receive payment for your treatment.

For Health Care Operations. For example, administrative personnel or others that perform services for UMMC may review your health information to review the quality and appropriateness of the care you receive.

For Fundraising Activities. We may contact you about UMMC fundraising activities. You will have the opportunity to opt out of any fundraising material and directions to do so will be included in that material. Your treatment does not depend on whether you decide to opt out of fundraising material or not.

Health Information Exchanges. We may make your health information available electronically to other healthcare providers or other healthcare entities for treatment, health care operations, or payment purposes by a state, regional, or national information exchange service. In doing this, we may receive information that they maintain about you so that you may have continuity in health care, treatment, or payments for health care services.

Uses and Releases That Do Not Require Your Permission

Emergencies. We may use or release your health information in an emergency treatment situation.

Food and Drug Administration. We may use and release your health information to a person or company required by the Food and Drug Administration to track adverse events and as otherwise required.

Workman’s Compensation. We may use and release your health information as necessary to comply with workman’s compensation laws and other similar legally-established programs.

Federal, State or Local Law. We may use and release your health information when required by law.

Government Agencies and Law Enforcement. We may release your health information to government agencies and law enforcement.

Ordered by a Court, Tribunal or Other Judicial Proceeding. We may release your health information when ordered by a court, tribunal or other judicial proceeding.

Public Health Reasons. We may use or release your health information for public health reasons.

Coroners, Medical Examiners and Funeral Home Directors. We may release your health information to a coroner, medical examiner or funeral home director.

Health Oversight Reasons. We may release your health information to the government to be used to oversee the healthcare system.

Organ and Tissue Donation. We may use and release your health information for organ and tissue donation.

Research Reasons. We may release your health information for reviews to prepare a research study and when approved by an institutional review board.

Disaster Relief Reasons. We may release your health information for the reason of coordinating disaster relief efforts.

Specialized Government Functions. We may release the health information of military personnel and veterans in certain situations to the government. We may also release your health information for national security reasons.

Avert a Serious Threat to Health or Safety. We may release your health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person, such as instances of child and/or elderly abuse or neglect.

De-Identified Protected Health Information. We may use or release your health information when it has been de-identified in compliance with HIPAA laws. De-identified information does not contain information that could be used to identify you.

Uses and Releases to Which You Have the Opportunity to Object

People Who Help Take Care of You. We may provide your health information to a family member, friend or other person, if they help take care of you, or if they are responsible for paying for your care, unless you tell us not to. In emergencies, you will not be given the chance to tell us not to provide information to those who take care of you.

Hospital Directory. If you are admitted to one of our hospitals or units, your name, location within the hospital and religious affiliation will be listed in the hospital directory, unless you tell us not to list you. This information may be released to persons who ask for you by name, such as family and friends, and to members of the clergy.

Other Uses and Releases Require Your Prior Written Permission

Psychotherapy Notes. Psychotherapy notes that may be written by a mental health professional regarding the contents of conversation held within a counseling session and are stored separately from the rest of your health information. Such notes will not be released unless both you and your provider agree.

Marketing. Marketing information typically may only be used or disclosed by UMMC if you provide UMMC with written permission to use or disclose your information.

Sale of PHI. We do not sell your health information.

Other uses and releases will be made, of your health information, only with your written permission. You may take back permission once you have given it and your refusal to provide permission will not be held against you; however, it may prevent us from completing a task you have requested, such as enrollment in a research study or to create a report for your attorney. The request to take back the permission must be made to UMMC in writing. You cannot take back permission if UMMC has already acted in reliance of the permission and as needed to maintain the integrity of a research study.


You have the right to see and to get copies of your health information. With only a few exceptions, you have the right to look at, or get hard copies or, with certain limitations, electronic copies of your health information that we have. You must make this request in writing. If we do not have your health information, but we know who does, we will tell you how to get it. We will respond to you within 30 to 60 days after receiving your written request. In certain situations, we may deny your request. If we do, we will tell you, in writing, our reasons for the denial and explain your right to have the denial reviewed. If you request copies of your health information, we may charge you a fee based on our cost. Instead of providing the health information you requested, we may provide you with a summary or explanation of the health information as long as you agree to accept a summary and to the cost in advance.

You have the right to request a correction to your health information. If you believe that your health information is incorrect or information is missing, you may request that the information be changed or added. You must make the request in writing. You must also give us a reason for your request. We will let you know if we accept your request within 60 days of receiving your request. Under certain circumstances, we may deny the request. If we deny your request, we will let you know why. We will also explain your right to file a written statement of disagreement with the denial. If we approve your request, we will make the change to your information. We will let you know when the change is made. We will also let concerned parties know when the change is made.

You have the right to request a listing of releases we have made of your health information. You have the right to an accounting of all entities that obtained information unrelated to treatment, payment, or healthcare operations without your permission, except as otherwise required by law. We will respond within 60 days of receiving your request. Your request must state the time period desired for the accounting, which must be less than a six-year period and starting after April 14, 2003. The list will contain the date of the release, the name of the recipient and address, if known, a description of the information released, and the reason for the release. If you make more than one request in the same year, you will be charged a fee based on cost for each additional request.

You have the right to request limits on uses and releases of your health information. You have the right to request a limit on the health information we use or release about you for treatment, payment or health care operations. UMMC will agree to all requests to limit releases of health information to a health plan when you have paid out of pocket in full for the healthcare item or service. All other requests will be considered and we are not legally required to accept them. If we accept your request, we will put any limits in writing and abide by them, except in some situations, such as during emergencies. You may not limit the uses and releases that we are legally required or permitted to make.

You have the right to choose how we communicate with you. You have the right to request that we communicate with you in a certain way. For example, you may request that we contact you by phone rather than by mail. We will agree to the request as long as we can easily provide it in the format you request. We require that you make requests for confidential communications in writing.

You have the right to receive notification in the event your health information is breached. In the event your unsecured protected health information is breached, we will notify you of the occurrence.

If you would like more information on accessing, obtaining a copy or obtaining a listing of the releases that we have made of your health information, you may call the following number: 1-855-241-2575

MS State Law: In some instances, Mississippi law is more limited than Federal law. Please contact the UMMC Privacy Officer if you have any questions regarding MS state privacy laws.


If you have any questions about this notice, complaints about our privacy practices or would like information on how to file a complaint with UMMC or the Secretary of the Department of Health and Human Services, please contact: the UMMC Privacy Officer, at The University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216 or call the Compliance Hotline at 601-984-4722. You will not be penalized or retaliated against for filing a complaint.

Acknowledgement of Receipt of Notice of Privacy Practices

I agree that I have received a copy of the UMMC Notice of Privacy Practices.*
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