In the course of 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 in order to treat you, to obtain payment for our services, and to conduct health care operations involving our office.
We have a comprehensive Privacy Policy 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 Privacy Policy, the use and disclosure of your health information for treatment purposes not only includes care and services provided here, but also disclosure of your health information as may be necessary or appropriate for you to receive follow-up care from another health care professional. Similarly, the use and disclosure of your confidential information for purposes of payment may include the submission of your personal information to a billing agent or vendor for processing claims or obtaining payment; our submission of your personal information to auditors hired by third-party payers and insurers, among other aspects of payment described in our Privacy Policy. Our Privacy Policy will be updated whenever our privacy practices change.
When you acknowledge 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 our services, and to perform mental health treatment. 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 our information in accordance with this consent. We can decline to serve you if you elect not to acknowledge this consent form.
You have the right to ask us to restrict the uses of disclosures made for purposes of treatment, payment or mental health treatment, but as described in our Privacy Policy, we are not obligated to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Privacy Policy describes how to ask for a restriction.
I HAVE READ THIS CONSENT AND UNDERSTAND IT. I CONSENT TO THE USE AND DISCLOSURE OF MY CONFIDENTIAL INFORMATION FOR PURPOSES OF TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS.