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
to:
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Conduct, plan, and direct my treatment and follow up among the multiple healthcare providers who may be involved
in that treatment directly and indirectly.
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Obtain payment from third-party payers.
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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.
