A basis for planning my care and treatment, A means of communication among the many health professionals who contribute to my care, A source of information ~or applying my diagnosis and surgical information to my bill, A means by which a thlrd-partY payer can verify that services billed were actually provided, and A tool for routine healthcare operations such as assessing quality. and reviewing the competence of healthcare professionals.
I understand and have been provided with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have ttie following rights and privileges:
The right to review the notice prior to signing this consent, The right to object to the use of my health information for directory purposes, and The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations.
I understand that Fertility & IVF Center of Miami Is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has alreaay take action In reliance thereon. I also understand that by refusing to sign this consent or revoking this consent this organization may refuse to treat me as permitted by Sacfion 164.506 of the Coda of Federal Regulations.
I further understand that Fertility & IVF Center of Miami reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should Fertility & IVF Center of Miami change their notice, they will make a copy of the revision available.
I hereby authorize the Fertility & JVF Center of Miami to disclose, without restrictions, any and all my health information to:
ANY POTENTIAi:. EGG RECIPIENT, INTENDED PARENT, AGENCY, AND ANY HEALTHCARE