I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information serves as:
• A basis for planning my care and treatment.
• A means of communication among the many healthcare professionals who contribute to my care.
• A source of information for applying my diagnosis and surgical information to my bill.
• A means by which a third-party payer can verify that services billed were actually provided.
• A tool for routing healthcare operatives such as assessing care quality and reviewing the competence of the healthcare professionals.
I understand that I have the right:
• To object to the use of my health information for directory purposes.
• To request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations – and that the organization is not required to agree to the restrictions requested.
• To revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.