I understand that under the Health Information Portability & Accountability Act of 1996 (HIPAA), , I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
Conduct, plan and direct my treatment and follow up among the multiple healthcare providers who may be involved in that treatment, directly or indirectly. Obtain payment from third party payers. Conduct normal healthcare operations such as quality assessments and physician certifications. Notification of any breaches in unsecured Protected Health Information
I have received and read and understand your Notices of Privacy Practices containing a more complete description of the usesand
disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact his organization to obtain a copy of the Notice of Privacy Practices.
I understand that I may request, in writing, that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree, they you are bound to abide by such restrictions.