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.
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, payment, or health care operations.