In this notice, "you" and "your" are also used to mean and pertain to "you" or to "your child" or "your children" where appropriate.
The providers (physicians, nurse practioners), nursing and administrative staff at our Practice, at the direction of the physicians, may share your health information for treatment, payment, and health care operations.
I understand that my health information may be used for treatment, payment or healthcare operations, such as:
1. Sharing my health information among providers (both insideand outside the practice), on a need-to-know basis, to give me treatment;
2. Using my health information for billing purposes, including giving referrals to specialists, when necessary and appropriate;
3. Sharing my health information with health insurance compaies, goverment agencies, or other payers that request inforamtion related to benefits determinations, claims filed for vistis or admission, and other billing matters;
4. Using my health information for healthcare operations, including monitoring the quality of care, audits and surveys, and carrying out other business and administrative activities.
I understand that all reasonable efforts will be made to protect the privacy of my health information whether maintainted on paper or electronically, and regardless of how it is communicated (paper, email, or fax).
I have been given the opportunity to read the Notice of Privacy Practices that outlines in more detail how my health care information is used and shared with others. The Notice of Privacy Practices explains (1) when I need to give further apporval for the providers to use my health information or share it outside the practice and (2) when my permission is not needed for the providers to use my health information or share it outside the practice (e.g. required by law, public health activities, etc.).
I understand that this Practice has reserved the right to change the Notice of Privacy Practices at any time. I may obtain a current copy of the Notice of Privacy Practices by contacting the Practice Manager or from the Practice's website.
My signature below consititues my acknowledgment that I have been provided a copy of the Notice of Privacy Practices.