I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand and I consent to the use or disclosure of my protected health information by Women’s Health Physicians and Surgeons for the purpose of: Conducting, planning and directing my treatment and follow-up among the multiple health care providers who may be involved in that treatment directly and indirectly, obtaining payment from third-party payers, and to conducting normal health care operations of Women’s Health Physicians and Surgeons, such as quality assessments and physician certifications.
I understand that I have a right to review Women’s Health Physicians and Surgeons Notice of Privacy Practices. I have received, read and understand the Notice of Privacy Practices document containing a more complete description of the uses and disclosures of my protected health information that will occur in my treatment, obtaining of payment, or in the performance of normal health care operations. I understand the Notice of Privacy Practices describes my rights and the duties of Women’s Health Physicians and Surgeons with respect to my protected health information. The Notice of Privacy Practices for Women’s Health Physicians and Surgeons is provided in various locations of the facility, to include the waiting area.
I understand that Women’s Health Physicians and Surgeons reserve the right to change the privacy practices described in the Notice of Privacy Practices. I may obtain a revised copy of the Notice of Privacy Practices document at any time by contacting this organizationat: 901 Leighton Avenue, Suite 103 ⧫ Anniston, AL 36207 ⧫ 256-405-0161