Consent to Use or Disclose Protected Health Information

Consent to Use or Disclose Protected Health Information For Treatment, Payment and Health Care Operations

I consent to allow Hudson Valley Pain Management to use or disclose my protected health information for treatment, payment and health care operations.

• Treatment means the provision, coordination, or management of health care and related services by one or more health care providers.
• Payment means the activities undertaken by a health care provider or health plan to obtain or provide reimbursement for the provision of health care.
• Health care operations means conducting quality assessment and improvement activities; reviewing the competence or qualifications of health care professionals; underwriting, premium rating, and other activities related to health insurance contracts; medical reviews; legal services; auditing functions; and business management and general administrative activities of the practice.

I consent to allow Hudson Valley Pain Management to disclose my protected health information for treatment activities of another health care provider.

I consent to allow Hudson Valley Pain Management to disclose my protected health information to another physician or to another health care provider for the payment activities of the entity that receives the information.

I consent to allow Hudson Valley Pain Management to disclose protected health information to another medical facility for health care operations activities, provided that the practice and the other entity has or had a relationship with the below named patient. The disclosure must be for treatment, payment, or health care operations or for the purpose of health care fraud and abuse detection or compliance.

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