I understand that, under the Health Insurance and Accountability Act of 1996 (HIPAA), I understand that the information can and will be used to:

Conduct, plan and direct my treatment and follow-up among multiple healthcare providers who may be involved in that treatment directly or indirectly.
Obtain payment from third-party payers.
Conduct normal healthcare operations such as quality assessments and physician certifications.

By signing this document, I acknowledge that you have provided me with a copy of your Notice of Privacy Practice. This Notice of Privacy Practices contains a more complete description of the uses and disclosures of your health information.
I understand that this organization has the right to change it's Notice Policy Practices from time to time and that I contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand your are not required to agree to my requested restrictions, but if you do agree then you are bound by such restrictions.