I understand that, under the Health Insurance Porability & Accountability Act of 1966, I have certin rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and follow up care among multiple healthcare providers who may be involved in that treatment directly or indirectly.
- Obtain payment from designated third party payers.
- Conduct normal healthcare operations such as quality assessments or evaluations and physisican certifictaions.
I have been informed by you or your notice of privacy practices which contains a more complete description of the uses and disclosures of my health information. It is available in your office in print form or on the office website www.sunrisemedicalaz.com. I’ve been given the right to review such notice of privacy practices prior to signing the consent. I understand that the organization has the right to change its notice from time to time and that I make contact this organization at any time to obtain a current copy of notice. I understand that I may request in writing that this organization restrict how my private information is used or disclose to carry out treatment, payment or healthcare operations. I also understand the organization is not required to agree to my requested restrictions but if the organization does agree, then it is bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time except to the extent that the organization has taken action relying on this consent.