HIPAA 
CONSENT TO USE OR DISCLOSE HEALTH INFORMATION 

FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS 

 

While providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information to treat you, to obtain payment for our services and to conduct health care operations involving our office.  

We have a comprehensive Notice of Privacy Practices that describes these uses and disclosures in detail.  You are free to refer to this notice at any time before you sign this consent document. As described in our Notice of Privacy practices, the use and disclosure of your health information for treatment purposes not only includes care and services provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes our submission of your health information to a billing agent or vendor for processing claims or obtaining payment; our submission of claims to third-party payers or insurers for claims review, determination of benefits and payment; our submission of your health information to auditors hired by third-party payers and insurers, among other aspects of payment described in our Notice of Privacy Practices.  Our Notice of Privacy Practices will be updated whenever our privacy practices change.  You can obtain a copy of the entire HIPAA upon request. 

When you sign this consent document, you signify that you agree that we can and will use and disclose your health information to treat you, to obtain payment for services and to perform health care operations. You can revoke this consent in writing at any time unless we have already treated you, sought payment for our services or performed health care operations in reliance upon our ability to use or disclose your health information in accordance with this consent. We can decline to serve you if you elect not to sign this consent form. 

You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment or health care operations, but as described in our Notice of Privacy Practices, we are not obligated to agree to these suggested restrictions.  If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.