Consent to Disclosure Information

understand that as part of my health care, Central Florida Pain & Rehab Clinic originates and maintains paper and/or electronic 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 between the many health professionals 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.
• 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 Privacy Practices that gives a complete description of information uses and disclosures. I understand that I have the following right and privileges:

• The right to review the notice prior to signing this consent.
• The right to object the use of my health information for directory purposes.
• The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations.

I understand that Central Florida Pain & Rehab Clinic is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extend that the organization has already taken action in reliance there on. I also understand that by refusing to sign or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

I further understand that Central Florida Pain & Rehab Clinic reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should Central Florida Pain & Rehab Clinic change their notice, they will send a copy of any revised notice to the address I have provided, (whether U.S. mail or if I agree email).

I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosure via fax.

I finally understand and accept the term of this consent.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Spanish Version: Por motivos legales el consentimiento del paciente debe estar consignado en este documento en inglés, pero si usted no tiene claridad con respecto a algo aquí relacionado, favor solicite la versión en español del mismo a nuestro personal.