Consent for Purposes of Treatment, Payment and Healthcare Operations

I consent to the use or disclosure of my protected health information by Thirlby Clinic for the purposes of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Thirlby Clinic. I understand that diagnosis or treatment of me by any Thirlby Clinic employed physician 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. Thirlby Clinic is not required to agree to the restriction that I may request. However, if Thirlby Clinic agrees to a restriction that I request, the restriction is binding on Thirlby Clinic and any Thirlby Clinic employed physician.

I have the right to revoke this consent, in writing, at any time, except to the extent that any Thirlby Clinic employed physician or Thirlby Clinic 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 clearinghouse. This protected health information relates to my past, present or future physician or mental health or 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 Thirlby Clinic's Notice of Privacy Practices prior to signing this document. The Thirlby Clinic's Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types and 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 Thirlby Clinic. The Notice of Privacy Practices for Thirlby Clinic is also provided at the front desk. This Notice of Privacy Practices also describes my rights and Thirlby Clinic's duties with respect to my protected health information.

Thirlby Clinic 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 calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.