ࡱ> :<9 Ybjbj 4$ UUUUUiiii}illlZ\\\\\\$]FQUlllllUUl UUZlZ02ivRF0>U0lllllllllllllllllllllll : CONSENT TO THE USE & DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS & ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF INFORMATION PRACTICES ______________________________________________________ I understand that as part of my healthcare, Blue Ridge Women's Health Center, P.L.C. originates & maintains health records describing my health history, symptoms, examination & test results, diagnoses, treatment, & any plans for future care or treatment. I understand that this information serves as: q A basis for planning my care & treatment q A means of communicating among health professionals who contribute to my care q A source of information for applying my diagnosis & treatment to my bill q A means by which a third party payer can verify that services billed were actually provided q A tool for routine healthcare operations such as assessing quality of care & reviewing the competence of healthcare professionals I understand & have been provided with a Notice of Information Practices that provides a more complete description of information uses & disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that Blue Ridge Women's Health Center, P.L.C. reserves the right to change the notice & practices but will notify me of such changes. 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 see & obtain copies of my medical record. I understand that I have the right to request amendments be made to my medical record. I understand that a six-year history of all disclosures will be accessible to me including the purpose of the disclosure & the address of the recipient. I may receive a copy of this history within 30 days of my request & I understand that I have to pay a reasonable charge of 50 cents per page for disclosure information & a charge of $38.00 for copying of my medical records. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations & that Blue Ridge Women's Health Center, P.L.C. is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the Practice has already taken action in reliance thereon. q I request the following restrictions to the use or disclosure of my health information. __________________________________________________________________________________________________________________________ **I am aware that if I am accompanhi4 5    , | ~ ( * , : 89W۹۹۹۹۹۹ʦU h]h]CJOJPJQJaJ h]h]CJOJPJQJaJ h]h]CJOJPJQJaJ h]h]CJOJPJQJaJ&h]h]5CJOJPJQJ\aJAi5  ~ * ddd[$\$^`gd]ddd[$\$^`gd]ddd[$\$gd]$ddd[$\$a$gd]ied by an individual (i.e., friend or family member) that is present at any point during my appointment, this individual will observe & overhear my confidential patient healthcare information. Blue Ridge Women's Health Center, P.L.C. cannot be held responsible for any breach of confidentiality by such an individual. 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