I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain 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 among the mutiple healthcare providers who may be involved in that treatment directly and indirectly.
Obtain payment from third party payer, (insurance carriers etc.)
Conduct normal healthcare operations
I hve received, read and understand you Notice of Privacy Practives containing a more complete description of the uses and disclosures of my health information. I understand that this practice has the right to change its Notice of Privacy Practices from time to timeand that I may contact this practice at any time to obtain a currect 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 healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.