PATIENT CONSENT AND ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE
I hereby give consent for Regional Primary Care to use and disclose protected health information (PHI) about me to carry out treatment, payment, and health care operations (TPO). The Notice of P-rivacy Practices provided by Regional Primary Care describes such uses and disclosures more completely. l understand that I have the right to review the notice prior to signing this consent. Regional Primary Care reserves the right to revise it Notice of Privacy Practices at any time. A revised Notice may be obtained by forwarding a written request to Regional
This consent is given freely with the understanding that:
1. Any and all records, whether written or oral or in electronic format, are confidential and cannot be
disclosed for reasons outside of treatment, payment, or health care operations without my prior written
authorization, except as otherwise provided by law.
2. A photocopy or fax of this consent is as valid as this original.
3. l have the right to request that the use of my Protected Health Information, which is used or disclosed for
in the purposes of treatment, payment, or health care operations be restricted. l also understand that the
Practice and I must agree to any restriction in writing that l request on the use and disclosure of my
Protected Health Information and agree to terminate any restrictions in writing on the use and disclosure
of my Protected Health Information which have been previously agreed upon.
4. I have the right to revoke this consent, in writing, except where disclosures have already been made in
reliance on my prior consent.
5. If I do not sign this consent or later revoke it, Regional Primary Care may'decline to provide treatment to me.
6. This consent will remain in effect until terminated by me in writing.