With my consent, PREMIER PEDIATRICS, may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to PREMIER PEDIATRICS. Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. PREMIER PEDIATRICS, reserves the right to revise its Notice of Privacy Practices at anytime. A revised notice of Privacy Practices may be obtained by forwarding a written request to PREMIER PEDIATRICS’ Privacy Officer at 185 N Milwaukee Ave., Suite 220, Lincolnshire, IL 60069.

With my consent, PREMIER PEDIATRICS, may mail to my home or other designated 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 my consent, PREMIER PEDIATRICS, may utilize e-mail to communicate clinical information to me pertaining to health care services. I understand and acknowledge that such e-mail may contain PHI. I acknowledge that although PREMIER PEDIATRICS may engage in certain practices to protect the privacy of e-mail contents sent to or received from me, the e-mail messages sent to me are not encrypted. As a result there is a risk that the e-mail will be intercepted and read by third parties to whom it was not directed. In authorizing PREMIER PEDIATRICS to send me e-mail, I assume the foregoing risk.