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Consent to the Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operations

I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination, 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 health professionals who contribute to my care.

  • A source of information for applying my diagnosis and treatment information to my bill.

  • A means by which a third-party payer can verify that services billed were actually provided.

  • A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

holly shuman


Use of Health Information Consent

I understand and have been provided with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I have read the Notice of Privacy Practices, have had the opportunity to ask questions regarding its content and meaning and fully understand its content and implication.


I understand that I have the right to review the notice prior to signing this consent.


I understand that the organization reserves the right to change their notice and practices and prior to implementation and will mail a copy of any revised notice to the address I've provided.


I understand that I have the right to request restrictions as to how my health information may be used or disclosed to car-ry out treatment, payment, or healthcare operation and that the organization is not required to agree to the restrictions. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.

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