CONSENT TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION
1. I give this practice/clinic my consent: to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews.
2. I have been informed: that I may review the practice/clinic Notice of Privacy Practices (for a more complete description of uses and disclosures) before signing this consent.
3. I understand that this practice/clinic: has the right to change its privacy practices and that I may obtain any revised notices at the practice/clinic.
4. I understand that I have the right to request a restriction: on how my protected health information is used. However, I also understand that the practice/clinic is not required to agree to the request. If the practice/clinic agrees to my requested restriction, they must follow the restriction(s).
5. I also understand that I may revoke this consent for the use or disclosure of my protected health information, at any time, by making a request in writing, except for information already used or disclosed.
