By signing the consent section of this Patient Privacy Consent Form, you have agreed that you have given your informed consent to collection, use and disclosure pf your personal information for the purposes that are listed herein. I a new purpose arises for use and/or disclosure of your personal information, we will seek your prior approval.
Your information may be assessed by regulatory authorities under the terms of Regulated Health Professionals Act (RHPA) and for the defence of legal issues.
Our office will not disclose under any conditions your health or medical information to your insurer. In the event of such request, we will inform you and if need be, forward the information to you for review and for your specific consent. When unusual requests are received, we will contact you for your permission to release such information. We may also advise you if such a release is inappropriate.
You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process.
I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking t protect my information.
I know that your office has a privacy code, and I can ask to see the code at any time.
Iagree that Dr. Prathana Davla can collect, use and disclose my personal Information.