My personal health information is private and confidential. I understand that my doctor and his/her staff work very hard to protect my privacy and preserve the confidentiality of my personal health information.
I understand that my doctor
and his/her staff may use and disclose my personal health information to help
provide health care to me, to handle billing and payment, and to take care of
other health care operations. There will
be no other uses and disclosures of this information unless I permit it. However, I understand that sometimes the law
may require the release of this information without my permission.
I can ask my doctor to limit
how my personal health information is used or disclosed to carry out treatment,
payment, or health care operations. I
understand that my doctor does not have to agree to my request. If my doctor does agree to my request, I
understand that my doctor and his/her staff will follow the agreed limits.
I may cancel this agreement
at any time by doing one of the following:
dating a form that my doctor or his/her staff can give me called “Revocation of
Consent for use and disclosure of Health Information” or
and dating a letter to my doctor directly.
If I write a letter, it must say that I want to cancel my consent to
authorize the use and disclosure of my personal health information for
treatment, payment and healthcare operations.
If I cancel this consent, my doctor and his/her
staff do not have to provide any further health care services to me.
My doctor has a detailed
document called the “Notice of Privacy Practices.” It contains more information about the
policies and practices protecting my privacy.
I understand that I have the right to read the “Notice” before signing
this agreement. My doctor may update
this “Notice”. If I ask , my doctor or
his/her staff will provide me with the most current “Notice” and the current
“Notice” will always be posted at my doctor’s office.
My signature below indicates
that I have been given the chance to review a current copy of my doctor’s
“Notice of Privacy Practices.” My
signature means that I agree to allow my doctor to use and disclose my personal
health information to carry out treatment, payment, and healthcare operations.