Patient Consent Form

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health insurance. I understand that this information can

Conduct, plan and direct my treatment and follow-up among multiple healthcare providers who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers Conduct normal healthcare operations such as quality assessments and physician certifications

I have been informed by you and your Notice of Privacy Practices containing a more complete

description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time, and that I may contact this organization at any time at the above address to obtain a current 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 you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such

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.