Memorial Mri And Diagnostic Form (Page 4 of 4) in pdf

Memorial MRI & Diagnostic

NOTICE OF PRIVACY PRACTICES

Patient Consent and Acknowledgment of Receipt of Privacy Notice

I understand that as part of the provision of healthcare services, Memorial MRI & Diagnostic creates and maintains

health records and other information describing among other things, my health history, symptoms, examination, and test

results, diagnoses, treatment, and any plans for future care or treatment.

I have been provided with a Notice of Privacy Practices that provides a more complete description of the uses and

disclosures of certain health information. I understand that I have the right to review the notice prior to signing this

consent. I understand that the organization reserves the right to change their Notice and practices and prior to

implementation will mail a copy of any revised notice to the address I have provided. I understand that I have the right to

object to the use of my health information for directory purposes. I understand that I have the right to request restrictions

as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations

(quality assessment and improvement activities, underwriting, premium rating, conducting or arranging for medical

review, legal services, and auditing functions, etc.) and that the organization is not required to agree to the restrictions

requested.

By signing this form, I consent to the use and disclosure of protected health information about me for the purposes of

treatment, payment and health care operations. I have the right to revoke this consent, in writing, except where

disclosures have already made in reliance on my prior consent.

This consent is given freely with the understanding that:

1. Any and all records, whether written or oral or in electronic format, are confidential and cannot be disclosed for reasons

outside of treatment, payment or health care operations without my prior written authorization, except as otherwise provided

by law.

2. A photocopy or fax of this consent is as valid as the original.

3. I have the right to request that the use of my Protected Health Information, which is used or disclosed for the purposes of

treatment, payment or health care operations be restricted. I also understand that the Practice and I must: agree to any

restriction in writing that I request on the use and disclosure of my Protected Health Information; and agree to terminate any

restrictions in writing on the use and disclosure of my Protected Health Information which have been previously agreed

upon.

_______________________________________________

__________________________________________

(PATIENT’S NAME PRINTED)

DATE

_______________________________________________

PATIENT’S SIGNATURE

(OR GUARDIAN, IF A MINOR)

Memorial Mri And Diagnostic Form Page 4