CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS
I understand that as a part of my healthcare, this organization 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 healthcare 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 care quality and reviewing the competence of healthcare professionals.
I understand that I have the right:
To read the office’s Notice of Privacy Practices before making the decision to sign.
To object to the use of my health information for directory purposes.
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 restrictions requested.
To revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.
Please check and write name:
to receive health information concerning treatment, payment, and healthcare operations.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (HIPAA)
**You may refuse to sign this acknowledgment**
have read and received a copy of this office’s Notice of Privacy Practices (HIPAA).
FOR OFFICE USE ONLY
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