Consent for Use & Disclosure of Protected Health Information

Evergreen Prosthetics & Orthotics, LLC

Print This!

Use & Disclosure of Your Protected Health Information
Your protected health information will be used by Evergreen Prosthetics & Orthotics, LLC or disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice.

Notice of Privacy Practices
You should review the Notice of Privacy Practices for a more complete description of how your protected health information may be used or disclosed. You may review the notice prior to signing your consent.

Requesting a Restriction on the Use or Disclosure of Your Information
You may request a restriction on the use or disclosure of your protected health information.
Evergreen Prosthetics & Orthotics, LLC may or may not agree to restrict the use or disclosure of your protected health information.
If Evergreen Prosthetics & Orthotics, LLC agrees to your request, the restriction will be binding on the practice. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards.

Revocation of Consent
You may revoke this consent to the use and disclosure or your protected health information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.

Reservation of Right to Change Privacy Practices
Evergreen Prosthetics & Orthotics, LLC reserves the right to modify the privacy practices outlined in the Notice.

Signature
I have reviewed this consent form and give my permission to Evergreen Prosthetics & Orthotics, LLC to use and disclose my health information in accordance with it.

_____________________________________________ ________________________

Consent for Use & Disclosure of Protected Health Information
Effective Date 09/01/2010