Westside Voice and Swallowing

SPEECH-LANGUAGE PATHOLOGY PRIVATE PRACTICE

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Privacy Rule of Patient Consent Agreement

Consent to the Use and Disclosure of Protected Health Information for
Treatment, Payment, or Healthcare Operations (§164.506(a))
I understand that:
• I have the right to review this Practice’s Notice of Information practices prior to signing this consent;
that this Practice reserves the right to change the notice and practices and that prior to implementation will mail a copy
of any notice to the address I’ve provided, if requested;
•

• I have the right to object to the use of my health information for directory purposes;
I have the right to request restrictions as to how my Protected Health Information may be used or disclosed to carry out
treatment, payment, or healthcare operations, and that this Practice is not required by law to agree to the restrictions
requested;
•

I may revoke this consent in writing at any time, except to the extent that this Practice has already taken action in
reliance thereon.

HIPAA Privacy Rule of Patient Authorization

Agreement

Authorization for the Disclosure of Protected
Health Information for Treatment, Payment, or
Healthcare Operations (§164.508(a))

I understand that as part of my healthcare, this Practice originates and maintains health records describing my
health history, symptoms, examination 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 health professionals who may contribute to my health 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;
• a tool for routine health care operations such as assessing quality and reviewing the competence of health care professionals.
I can be provided with a copy of the Notice of Privacy Practices that provides a more complete description
of information uses and disclosures.
I understand that as part of my care and treatment it may be necessary to provide my Protected Health
Information to another covered entity. I have the right to review this Practice’s notice prior to signing this
authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes
and to the parties designated by me.

NO mobile information will be shared with third parties/affiliates for marketing/promotional purposes.  All of the of the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.