Disclosure Of Protected Health Information

Recovering from an injury or managing a chronic condition often requires more than just traditional medical care.


Consent for use and/or disclosure of Protected Health Information (PHI) to Carry out Treatment

Payment and Healthcare Operations.

As the person signing this authorization, I understand that by signing this Consent, I acknowledge and agree as follows:

  • I understand I have the right to request the Practice restrict how my PHI is used and/or disclosed to carry out treatment, payment and/or health care operations. However, the Practice is not required to agree to any restrictions I have requested. If the Practice agrees to a requested restriction, the restriction is binding on the Practice. 
  • The original or copy of the authorization will be included in my medical record. 
  • I have the right to revoke this authorization at any time, except to the extent that action has been taken prior to my request to withhold my medical record. The request must be in writing and will be effective upon delivery to the provider in possession of my medical records. 
  • I understand if I revoke this consent at any time, the Practice has the right to refuse to treat me. ● The Practice may use and/or disclose my PHI (which includes information about my health or condition and the treatment provided to me) in order for the Practice to treat me and obtain payment for that treatment, and as necessary for the Practice to conduct specific health care operations. 
  • I understand and consent to the following appointment reminders will be used by the Practice a) by telephoning my home or workplace and leaving a message on my voicemail or with the individual answering the call. b) electronically via email c) text messages. 
  • The Practice reserves the right to change its privacy practices which are described in accordance with applicable law. ● I understand if I do not sign this Consent evidencing my consent to the uses and disclosures described to me above the Practice will not treat me. 


I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way in which I understand. Initial the following which is applicable: 

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