hereby authorize Gary I. Gorodokin, M.D. to use and/or disclose my health information that specifically identifies me or which can reasonably be used to identify me to carry out my treatment, payment, and health care operations. I understand that while this consent is voluntary, if I refuse to sign this consent, Gary I. Gorodokin, M.D. can refuse to treat me.
I have been informed that Gary I. Gorodokin, M.D. has prepared a notice (“Notice”) which more fully describes the uses and disclosures that can be made of my individually identifiable health information for treatment, payment and health care operations. I understand that I have the right to review such Notice prior to signing this consent.
I understand that I may revoke this consent at any time by notifying Gary I. Gorodokin, M.D. in writing, but if I revoke my consent, such revocation will not affect any actions that Gary I. Gorodokin, M.D took before receiving my revocation.
I understand that Gary I. Gorodokin, M.D. has reserved the right to change his privacies and that I can obtain such changed notice upon request.
I understand that I have the right to request that Gary I. Gorodokin, M.D. restricts how my individually identifiable information is used and/or disclosed to carry out treatment, payment or health operations. I understand that Gary I. Gorodokin, M.D. does not have to agree to such restrictions, but that once such restrictions are agreed to, Gary I. Gorodokin, M.D. must adhere to such restrictions.