Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations
I understand that as part of my health care, the practice 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 this information serves as:
* A basis for planning my care and treatment,
* A means of communication among health professionals who contribute to my care,
* A source of information for applying my diagnosis and treatment 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 staff.
* To disclose, as many be necessary, your health information (including HIV-v/AIDS status, drug and alcohol treatment/abuse notes and qualified mental health notes to other healthcare providers and facilities (such as referrals to or consultations with, other healthcare professionals, labs and hospitals) or any others as may be required by law or court order concerning your treatment payment and /or healthcare.
* To request from another healthcare entity and/or healthcare providers (ie doctors, dentists, hospitals, labs, imaging centers etc) specific healthcare information we may need for planning your care and treatment.
I have been provided the opportunity to review the "Notice of Patient Privacy Information Practices" that provides a more complete description of information uses and disclosures. I understand that I have the following rights:
* The right to review the "Notice" prior to acknowledging this consent,
* The right to restrict or revoke the use or disclosure of my health information for other uses or purposes, and
* The right to request restrictions as to how my health information may be used or disclosed to carry out treatment,
I request the following restrictions on the use or disclosure of my health information