I understand that, under the Health Insurance Privacy & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my health information. I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple health care providers who my be involved in that treatment directly and indirectly.
- Obtain payment from third-party payers.
- Conduct normal health care operations such as quality assessments and physician certifications.
I have received, read and understand 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 at 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 requested restrictions but if you do agree you are bound to abide by such restrictions.