CONSENT FOR RELEASE OF INFORMATION FOR TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS

hereby authorize Anne Thai M.D. to use and/or disclose my health information which specifically identifies me or which can reasonably be used to identify me to carry out my treatment, payment, and healthcare operations. I understand that while this consent is voluntary, if I refuse to sign this consent, Anne Thai M.D. can refuse to treat me.

I have been informed that Anne Thai M.D. has prepared a notice ("Notice"), which more fully describes the uses and disclosures that can be made of my individually identifiable health information for treatment, payment, and healthcare operations. I understand that I have a right to review such Notice prior to signing this consent.

I understand that I may revoke this consent at any time by notifying Anne Thai M.D. in writing. If I revoke my consent, such revocation will not affect any actions that Anne Thai M.D. took before receiving my revocation.

I understand that Anne Thai M.D. has reserved the right to change her privacy practices and that I can obtain such changed notice upon request.

I understand that I have the right to request that Anne Thai M.D. restrict how my individually identifiable health information is used and/or disclosed to carry out treatment, payment, or health operations. I understand that Anne Thai M.D. does not have to agree to such restrictions but that once such restrictions are agreed to, Anne Thai M.D. must adhere to such restrictions.

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.