Rosemark WomenCare Specialists

Patient Privacy Consent

By signing this form, you are acknowledging that you have received, reviewed, and understand our Notice of Privacy Practices, and that you are granting consent for Rosemark WomenCare Specialists and it’s affiliates to use and disclose your private health information for the purpose of treatment, payment, and healthcare operations.  The Notice of Privacy Practices contains detailed information about how we may use and disclose your private health information.   You have a legal right to review our Notice of Privacy Practices before you sign this consent, and we encourage you to read this notice in full.

Our Notice of Privacy Practices is subject to change.  If we change our notice, you may obtain a copy of the revised notice by accessing our website at www.rosemark.net or contacting our office at 557-2900.

You have the right to request a restriction on how we use and disclose your private health information. This request must be specific and must be in writing.  If it is determined that it is not in our best judgment to do so, or if it would pose potential risk or harm, or interfere with treatment, payment, or healthcare operations, we may be unable to grant your request.  If there is not a written request with specific disclosure restrictions, it is understood that we will abide by the disclosure practices defined in our Notice of Privacy Practices.

You have the right to revoke this consent in writing, except to the extent we already have used or disclosed your personal health information in reliance on your consent.

Printed Name: _____________________________

Signature: _________________________________

 Date:    ____________________________________

                   

Per Health Insurance Portability and Accountability Act (HIPAA)

Valid 6 years from signature date.

Updated 8/23/2007. All rights reserved.