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

understand that as part of my health care, E. W. Myofascial Therapies originates and maintains paper and/or electric records describing health history, symptoms, examination, and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this form serves as:

• A basis for planning my care and treatment including phone message notifications to you about appointments;
• A means of communication among the many health 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, and A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

I understand and have been provide with a Notice of Information Practices provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

• The right to review the notice prior to signing this consent
• The right to request restrictions as how to my health information may be used or disclosed to carry out treatment, payment, or health care operations

I understand that E. W. Myofascial Therapies is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

I further understand that E. W. Myofascial Therapies reserves the right to change their notice and practices in accordance with Section 164.520 of the Code of Federal Regulations. Should E. W. Myofasical Therapies change their notice, I will receive a revised notice at the next visit.

I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax or electronically.

I fully understand and accept/ decline the terms of this consent.