I understand that I have certain rights to privacy regarding my protected health information.  These rights are given to me under the Health Insurance Portability and Accountability Act (HIPAA) of 1996.  I understand that by signing this consent I authorize PCCi to use and disclose my protected health information to carry out:

·         Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment).

·         Obtaining payment from third party payers (e.g. my insurance company).

·         The day-to-day healthcare operations of this practice.

I have also been informed of and given the right to review and secure a copy of PCCi’s Notice of Privacy Practices which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA.  I understand that PCCi reserves the right to change the terms of this notice from time to time and that I may contact PCCi at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that PCCi is not required to agree to these requested restrictions.  However, if PCCi does agree, PCCi is then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time.  However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.