- You understand that you have certain rights to privacy regarding your protected health
information. These rights are given to you under the Health Insurance Portability and
Accountability Act of 1996 (HIPAA). You understand that by signing this consent you
authorize us to use and disclose your protected health information to carry out:
Treatment (including direct or indirect treatment by other healthcare providers
involved in your treatment) - Obtaining payment from third party payers (e.g. your insurance company)
- The day to day healthcare operations of our practice
You have also been informed of, and given the right to review and secure a copy of your
Notice of Privacy Practices, which contains a more complete description of the uses and
disclosures of your protected health information, and your rights under HIPPA. You
understand that you reserve the right to change the term of this notice from time to time
and that you may contact us at any time to obtain the most current copy of this notice.
You understand that you have the right to request restrictions on how your protected health
information is used and disclosed to carry out treatment, payment, and health care
operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are bound to comply with these restrictions.
You understand that you may revoke this consent, in writing, at any time. However, any use of
disclosure that occurred prior to the date you revoke this consent is not affected.