| understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can, and will be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly or indirectly.
- Obtain payment from third party payers
- Conduct normal healthcare operations such as quality assessment and physicians’ certifications.
I have been informed by you of your Notice of Privacy Practices containing a more complete description of uses and disclosures of my health information. I have been given the right to review such Notices 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 East Alabama Primary Care, at any time at the address above to obtain a current copy of the Notices of Privacy Practices.
I understand that I may request in writing that you restrict how my confidential information is used or disclosed to conduct treatment, payment, or healthcare operations. L also understand
that you are not required to agree to my requested restriction, but if you do agree then you are bound to abide by such restrictions.
I understand that I may revoke this consent in writing at any time, except to the extent that you have acted relying on this consent.