PATIENT CONSENT TO STORE AND SHARE INFORMATION
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our notice before submitting personal data and prior to any service being provided to you by the practice. The Practice reserves the right to change the Notice of Privacy Policies. If we change our notice, you may obtain a revised copy by sending a letter to the Practice’s Data Protection Officer or by asking the provider’s receptionist.
By accepting these conditions, you acknowledge that you have been given the opportunity to read the clinic’s Notice of Privacy Practices prior to any service being provided to you by this Practice, and you consent to store, use and disclosure of your medical information to other healthcare providers involved in your care and for treatment, payment and healthcare operations.You have the right to revoke this consent in writing, signed by you.However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent.The Practice provides this form to comply with the General Data Protection Regulation (GDPR) (Regulation (EU) 2016/679)
By accepting these conditions, I understand that:
- Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
- The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
- The practice may condition receipt of treatment upon execution of this consent.