This consent will apply to all healthcare providers employed by and acting
for the benefit of this office who conducts, plan and direct treatment
and follow-up and be involved in treatment, directly or indirectly. In
the course of providing services to you, this office will create, receive,
and store health information that identifies you. It is often necessary
to use and disclose information in order to treat you, to obtain payment
for services and to conduct day to day health care operation. the Notice
of Privacy Practices describes the uses and disclosures in detail. The
use and disclosure of your health information may include care and services,
follow-up care from another health professional, disclosure or your information
for billing purposes or processing claims for obtaining payment or submission
of claims to a third-party payer or insurer. You have the right to restrict
the use or disclosure made for purposes of treatment or healthcare operations,
but this office is not obligated to agree to these restrictions. If this
office does agree, however, the restrictions are binding. You may revoke
this consent in writing at any time, except to the extent that this office
has taken action relying on this consent.