I understand that, under the Health Insurance Portability and Accountability Act of 1966, I have the right to privacy regarding my protected health information. I understand that this can be used to:
- Conduct, plan and direct my treatment and follow up care among the multiple healthcare providers who may be involved in the treatment directly or indirectly.
- Obtain payment and designated third-party payers.
- Conduct normal healthcare operations such as quality assessment or a evaluations and physician certifications.
I have been informed by you or your Notice of Privacy Practices which contains a more complete description of the uses and disclosures of my health information. It is available in the office and online for printing on our website. I understand that the organization has the right to change its notice from time to time and that I may contact this organization at any time to obtain a current copy of this notice. I understand that I may request in writing that this organization restrict how my private information is used or disclose to carry out treatment, payment, or healthcare operations. I also understand the organization is not required to agree with the requested restrictions but if the organization does agree, then it is bound to abide by such restrictions. I understand that can revoke this consent in writing at any time except to the extent that the organization is take an action relying on this consent.