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
● Conduct normal healthcare operations such as quality assessments and physician certifications.
I have received, read and understand the Notice of Privacy Practices containing a more complete description of the uses and disclosure of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and I may contact the organization at any time 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 and disclosed to carry out treatment, payment, or health care operations. I also understand you are required to agree to my requested restrictions and if you agree then you are bound to abide by such restrictions.
