Consent for Use or Disclosure of Health Information

Our Policy Pledge

We are very concerned with protecting your privacy.  While the law requires us to give you this disclosure,

please understand that we have, and always will, respect the privacy of your health information.

There are several circumstances in which we may have to use or disclose your health care information.

• We may have to disclose your health information to another health care provider or a hospital if it

is necessary to refer you to them for the diagnosis, assessment or treat of your health condition.

• We may have to disclose your health information and billing records to another party if they are

 potentially responsible for the payment of your services.

• We may need to use your health information within our practice for quality control or other

        operational purposes.

We have a more complete notice that provides a detailed description of how your health information may

be used or disclosed.  You have the right to review that notice before you sign this consent form (§164.520).

We reserve the right to change our privacy practices, we will notify you in writing when you come in for

treatment or by mail.  Please feel free to call us at any time for a copy of our privacy notices.

Your right to limit uses or disclosures

You have the right to request that we do not disclose your health information to specific individuals,

companies, or organizations.  If you would like to place any restrictions on the use or disclosure of your

health information, please let us know in writing.  We are not required to agree to your restrictions.

However, if we agree with your restrictions, the restriction is binding on us.

Your right to revoke your authorization

You may revoke your consent to us at any time: how3ever, your revocation must be in writing.  We will not

be able to honor your revocation request if we have already released your health information before

we receive your request to revoke your authorization.  If you were required to give your authorization as

a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.