NOTICE OF PRIVACY PRACTICES AND PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain Patient Rights regarding my protected health information.
I understand that Walnut Hill OB/GYN may use or disclose my protected health information for treatment, payment or health care operations-which means for providing health care to me, the patient handling billing and payment; and taking care of other health care operations. Unless required by law, there will be no other uses and disclosures of this information without my authorization.
Walnut Hill OB/GYN has a detailed document called the “NOTICE OF PRIVACY PRACTICES.” It contains a more complete description of your rights to privacy and how we may use and disclose protected health information.
I understand that I have the right to read the “Notice” before signing the agreement. If I ask, Walnut Hill OB/GYN will provide me with the most current Notice of Privacy Practices.
SMS Privacy Policy
No mobile information will be shared with third parties/affiliates for marketing or promotional purposes. All categories mentioned in this Privacy Policy exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.
My signature below indicates that I have been given the chance to review such copy of the Notice of Privacy Practices. My signature means that I agree to allow Walnut Hill OB/GYN to use and disclose my protected health information to carry out treatment, payment, and health care operations. I have the right to revoke this consent in writing at any time, except to the extent that Walnut Hill OB/GYN has taken action relying on this consent.