I understand that as part of my healthcare, this facility creates and maintains health records describing my health history.
1. a basis for planning my care and treatment
2. a means of communication among many health professionals who contribute to my care.
3. a means by which third-party payers can verify that services billed were actually provided; and
4. a tool for routine health care operations such as assessing quality and reviewing the competence of health care professionals.
I have been provided a Notice of Privacy Practices, which provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that this facility reserves the right to change its notice and practices. If the facility changes the notice, I can obtain a revised copy by asking the administrator. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or other health care operations and the facility is not required to agree to the restirctions requested. If the facility does agree to such restrictions , however, they must comply with such restrictions. I understand that I may revoke this consent in writing, except to the extent that the facility has already taken action in reliance on it.
HIPPA privacy rule gives individuals the right to request a restriction on uses and disclosures of their Protected Health Information (PHI). The Individual can also request that confidential communication, whether telephone communication or correspondence, be directed to an alternate site such as the individual's office.
I request the following restrictions to the use or disclosure of my health information: