Consent for Release of Protected Health Information
consent to the release of protected health information that is required to carry out treatment, payment of healthcare operations on my behalf.
I have read the Notice of Privacy Practices and am aware of the following:
- I have the right to place restrictions on the way my protected health information is used or disclosed.
- I have the right to revoke my consent for the use and disclosure of my protected health information at any time. I understand that, if I choose to revoke my consent, I must submit a written statement that is signed by me.
- I understand that Beatrice Keller Clinic must immediately comply with my request to revoke consent, except to the extent that it has already taken some action that was based on my original consent.
- Beatrice Keller Clinic has reserved the right to change from time to time its privacy practices that are described in the Notice of Privacy Practices. Whenever we change our practices, we will modify the Notice accordingly; and we will inform you by placing the amendment date at the bottom of the posted Notice.
I understand that occasionally Beatrice Keller Clinic may need to contact me concerning health matters. On these occasions I give my permission to: