CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS


I, __________________________________ understand that as part of my healthcare, this practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment, I understand that this information serves as:
  • A basis for planning my care and treatment,
  • A means of communication among the many health professions who contribute to my care,
  • A source of information for applying my diagnosis and surgical information to my bill,
  • A means by which a third-party payer can verify that services billed were actually provided, and
  • A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

I understand and have been provided with a NOTICE OF INFORMATION PRACTICES that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing the consent. I understand that the organization reserves the right to change its notices and practices and prior to implementation, will mail a copy of any revised notice to the address I've provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.

I wish to have the following restrictions to the use or disclosure of my health information


I fully understand and accept/decline the terms of this consent.


PATIENT'S SIGNATURE


DATE OF INITIAL VISIT
(expires 1 year)