I understand that, under the Health Insurance Portability & Accountability Act of 1196 (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 been informed by you of 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 prior to signing this consent. I understand that this organization has the right
to change the Notice of Privacy Practices from time to time and that I may contact this
organization at any time at the address above to obtain a current copy of the Notice of Privacy
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 restrictions.
I understand that I may revoke this consent in writing at any time, except to the extent that you
have taken action relying on the consent.