I understand that, under
the Health Insurance Portability & Accountability Act of 1996 (HIPPA), 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 read and understand
your Notice of Privacy Practices containing a more complete description
of the uses and disclosures of my health information. I understand that this
organization has the right to change its Notice of Privacy Practices from
time to time and that I may contact the organization at any time at the address
below to obtain a current copy of the Notice of Privacy Practices.
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. |
