I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I have certain rights regarding my protected health
information. I understand that this information can and will be used to:
I have received read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my
health information. I understand that this office has the right to change its Notice of Privacy Practices from time to time and that I may contact this
office at any time to obtain a current copy
- Conduct. Plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment
directly and indirectly.
- Obtain payment from third-party payers.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment or payment. I
also understand you are not required to agree to requested restrictions, but if you do agree, then you are bound to abide by such restrictions.
I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.