I understand that as part of my health care, Advanced Fertility Group oritinates and maintains paper and / or electronic records describing my health history, symptoms, examinations, and test results, diagnosis, 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 health care operations such as assessing quality and reviewing the competency of health care professionals.
I understand and have been provided with a NOTICE OF PRIVACY PRACTICES that provides a more complete description of the information uses and disclosures. I understand that I have the following rights and privileges: The right to review the notice prior to signing the 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 disclosed to carry out treatment, payment, or health care operations.
I understand the Advanced Fertility Group 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 by refusing to sign the consent or revoking this consent, Advanced Fertility Group may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.
I further understand that Advanced Fertility Group reserves the right to change their notice and practices prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should we change our notice, we will send a copy of any revised notice to the address I’ve provided via United States Mail.
I understand that as part of this organization’s treatment, payment, or health care operation, it may become necessary to disclose my protected health information to another entity, such as a referred health service or M.D. on your behalf, and I CONSENT to such a disclosure for these permitted uses, including via fax.
I understand and have been provided with a NOTICE OF PATIENT CONCERNS POLICY AND PROCEDURES that provides information regarding patient concerns related to Advanced Fertility Group.
In addition to my insurance provider THE FOLLOWING PERSON OR PERSONS may have access to my health information besides indicated providers as previously mentioned. I full understand and accept the terms of this consent.