Patient Privacy Protection Form

Patient Privacy Protection Form
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our Notice before signing this Consent. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on you prior Consent.
The patient understands that:
Protected health information may be disclosed or used for treatment, payment or health care operations.All other disclosures by the practice will require specific authorization by you unless required by law.The Practice has a Notice of Privacy Practices and that the patient can review this Notice and receive a copy.The patient has the right to restrict the uses of their information used for treatment, payment oroperations, but the Practice does not have to agree to those restrictions.
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