I consent to the use or disclosure of my protected
health information by Catskill Rehabilitation and Sports Medicine
for the purpose of diagnosing or providing treatment to me, obtaining
payment for my health care bills or to conduct health care operation
of CRSM. I understand that diagnosis or treatment of me by the practitioners
of CRSM may be conditioned upon my consent as evidenced by my signature
on this document.
I understand I have the right to request a restriction as to how my
protected health information is used or disclosed to carry out treatment,
payment or healthcare operations of the practice. CRSM is not required
to agree to the restrictions that I request. However, if CRSM agrees
to a restriction that I request, the restriction is binding on CRSM
and its practitioners.
I have the right to revoke this consent, in writing, at any time,
except to the extent that CRSM has taken action in reliance on this
consent.
My "protected health information" means health information,
including my demographic information, collected from me and created
or received by my physician, another health care provider, a health
plan, my employer or a health care clearing house. This protected
health information relates to my past, present or future physical
or mental health condition and identifies me, or there is a reasonable
basis to believe the information may identify me.
I understand I have a right to review CRSM's Notice of Privacy Practices
prior to signing this document. The CRSM's Notice of Privacy Practices
has been provided to me. The Notice of Privacy Practices describes
the types of uses and disclosures of my protected health information
that will occur in my treatment, payment of my bills or in the performance
of health care operations of the CRSM. The Notice of Privacy Practices
for CRSM is also provided by the Privacy Officer. This Notice of Privacy
Practices also describes my rights and the CRSM's duties with respect
to my protected health information.
CRSM reserves the right to change the privacy practices that are described
in the Notice of Privacy Practices. I may obtain a revised notice
of privacy practices by requesting one by calling the office and requesting
a revised copy be sent in the mail or by asking for one at the time
of my next appointment.