CONSENT TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
How we may use and disclose your health information: Your protected health information will be used by Hayley Nguyen, MD or disclosed to others for the purpose of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice.
The notice of privacy practices: Hayley Nguyen, MD is required to provide to you a notice that describes how information about you may be used and disclosed. Additionally, we must provide you information on how you may get access to this information. These policies and practices are defined in our “Notice of Privacy Practices” packet provided to you.
You may place restrictions on the use or disclosure of your health information: You may request a restriction on the use or disclosure of your protected health information. However, Hayley Nguyen MD may or may not agree to your request to restrict the use or disclosure.
You may revoke this consent at any time: You may revoke this consent at any time; however, Hayley Nguyen, MD requires that you revoke this consent in writing. If you revoke this consent, the revocation will not affect use and disclosure of your information before the date of the request.
Changes to privacy practices: Hayley Nguyen, MD reserves the right to change or modify the privacy policies outlined in the Notice of Privacy Practices packet. You will be notified of changes via mail or verbally.