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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 that this information can and will be used to:
I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information.
I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.
The following people have my permission to obtain information that is protected by the HIPAA Privacy Notice: