Consent to Use and Disclosure of Health information for Treatment, Payment or Healthcare operations

Patient name: *

I understand that as part of my health care, Warren J. STrudwick Jr. MD, and / or Bay Area Orthopaedic Sports Specialist (BOSS) originates and maintains paper and/ or electronic 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 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

INITIAL *

I understand and have been provided with a Notice of Health Information Practices that provides a more complete description of information uses and disclosures as permited under federal and state law. I understand that I have the following rights and privilleges:

- The right to review the notice prior to signing this consent
- The right to object to the use of my health information for directory purposes, and
- The right to request restrictions as to how my health information may be used or disclosed to carry our treatment, payment, or health care operations

INITIAL *

I understand that Warren J. Strudwick Jr. MD, are not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that th organization has already take action in reliance theron. I also understand that by refusing to sign this consent or revoking this consent, this organation may refuse to treat me as permitted by section 164.506 of the code of federal regulations.

INITIAL *

I further understand that Warren J. Strudwick Jr. MD, reserves the right to change their notice and practices and prior to implementation in accordance with section 164520 of the Code of Federal regulations.

INITIAL *

I wish to have the following restrictions to the use or disclosure of my health information:

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. Further I permit a copy of this authorization to be used in place of the original (if an original exists), and request payments of medical insurance benefits either to myself or to the party who accepts assignment. regulations pertaining to medical assignment of benefits apply. I fully understand and accept the terms of this consent. *

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If not signed by patient, please indicate your name and relationship to patient (e.g. Tom Johnson / Spouse)

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