I understand that, under the Health Insurance 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 and indirectly
- --Obtain payment from third party payers
- --onduct normal healthcare operations such as quality assessments and physician certifications
- I have been informed by you of your Notice of Privacy Practices describing 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 to obtain a current copy of Notice Of Privacy Practices.
-I Understand that I may request in writing that you restrict how my private information is used and/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 restrictions.
-I understand that l may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.
-I hereby authorize you to use or disclose the specific information described below, only for the purposes and parties also described below.
- Description of specific information to be used and/or disclosed: Insurance Company Name. Subscriber ID and information. treatment and treatment plan. medical history and x-rays.
- Person or entit y requesting and receiving the information and authorized to make the requested use of disclosure: Insurance, Laboratory, Specialist and any additional authorized persons listed below.