By signing below, I acknowledge the following statements:
I understand the Health Insurance Portability & Accountability Act of 1996 (HIPAA) grants me certain rights to the privacy of my protected health information. I understand my healthcare information may be used or disclosed for treatment, payment, healthcare operations, or as required by law. I acknowledge that Academy Orthopedics, LLC has a Notice of Privacy Practices and I have the right to review or request a copy of this Notice prior to signing this agreement. I further understand I may request an additional copy of the Notice of Privacy Practices at any time in the future.
I hereby authorize Academy Orthopedics, LLC to discuss my medical and/or billing information with the person(s) listed above. I understand that my information or records may include information regarding HIV, psychiatric and mental illness, drug/alcohol abuse records, venereal disease, and any other statutory protected diseases. I may revoke these privileges in writing at any time.