AUTHORIZATION FOR USE OR DISCLOSURE OF



AUTHORIZATION FOR USE OR DISCLOSURE OF

HEALTH INFORMATION

This notice describes how medical information about you may be used

and disclosed and how you can get access to this information. Additional information is located in the HIPAA Compliance Manual at the front desk of this facility, including the names and addresses of the privacy officer and complaints department. This regulation is required by law as a result of the Health Insurance Portability and Accountability Act of 1996. PLEASE REVIEW IT CAREFULLY.

INDIVIDUAL RIGHTS: You have certain rights under the federal privacy standards. These include the right to:

1) Request restrictions on the use and disclosure of your protected health information

2) Receive confidential communications concerning you medical condition and treatment

3) Inspect and copy your protected health information

4) Amend or submit corrections to your protected health information

5) Receive an accounting of how and to whom your protected health information has been disclosed

6) Receive a printed copy of this notice

PLEASE NOTE THAT IT IS THE POLICY OF THIS OFFICE THAT YOUR PHYSICIAN GIVE YOU THE RESULTS OF YOUR MRI.

USES AND DISCLOSURES: Your health information may be used:

A) Treatment: by staff member or disclosed to other health care professional for the purpose of evaluating your health, diagnosing medical conditions and providing treatment.

B) Payment: to seek payment from your health plan or other companies or services.

C) Health care operations: training of new employee, to support the daily activities and management of Central Texas Open MRI.

D) Law enforcement: to support government audits, inspections, investigations and mandated government reporting.

E) Public health reporting: to public health agencies in reference to certain communicable diseases as required by law.

F) Other: for confirmation of your appointment.

Central Texas Open MRI is required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice.

1. I hereby authorize the use and disclosure of individually identifiable health information relating to me, which is called “protected health information” under a federal health privacy law, as described below:

2. I understand that if the person or entity that receives this information is not a health plan or health care provider covered by federal privacy regulations, the release information may be re-disclosed by the recipient and may no longer be protected by federal or state law.

3. I understand that I may revoke this authorization at any time by notifying Central Texas Open MRI in writing. However, if choose to do so, I understand that my revocation will not affect any actions taken by Central Texas Open MRI before receiving my revocation.

4. I understand that I may refuse to sign this authorization and that my refusal to sign in no way affects my treatment, payment, and enrollment in a health plan, or eligibility for benefits.

Acknowledgement of Receipt of Notice of Privacy Practices

Central Texas Open MRI reserves the right to modify the privacy practices outlined in the notice.

Print Name of Patient: __________________________________________________

Signature of Patient: __________________________________________________

Patient’s DOB: ________________________Today‘s Date: ________________

For Personal Representative of the Patient (if applicable):

Print Name of Personal Representative: _____________________________________

(parent, guardian, etc.)

Signature of Personal Representative: ______________________________________

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