I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain
rights to privacy regarding my protected health information, I understand that this information can and will be used
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 acknowledge that I have received 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 this organization at any time the address above
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
personal requested restrictions, but if you do agree then you are bound to abide by such restrictions.