I hereby consent to the use and disclosure of health information for treatment, payment, or
healthcare operations. I understand that as part of my healthcare, this organization originates
and maintains health records describing my health history, symptoms, examination and test
results, diagnoses, treatment, and any plans for future care or treatment.
I understand that this information serves as:
- a basis for planning my care and treatment
- a means of communication among the health professionals who contribute to my care
- a source of information for applying my diagnosis and surgical information to my bill
- a means by which a third-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 the
right to review the notice prior to signing this consent. I understand that the organization
reserves the right to change their notice and practices and prior to implementation will mail
a copy of any revised notice to the address I have provided.