I understand that, under the Health Insurance Portability & Accountability Act (HIPPA), I have a certain right to privacy regarding my protected health. I understand that this information can and will be used to:

Plan and direct my treatment and follow-up among multiple healthcare providers that may be involved with my treatment directly and indirectly.

Conduct normal healthcare operations such as quality assessmenst.

I have received and understand the Notice of Privacy Practices containing a more complete description of the uses of my health information. I understand that Rebecca M. Jones, M.D. reserves the right to revise this notice at any time and that a current copy of this notice can be obtained upon request.

I understand that I may request in writing to Rebecca M. Jones, M.D. , restrict how my private information is used or disclosed. I also understand that Rebecca M. Jones, M.D. is not required to agree to my requested restrictions, but if she does agree then Rebecca M. Jones is bound to abide by such restrictions.

***** Do we have permission to (check YES or NO below)

Leave messages on your answering machine regarding appointment? YESNO

Regarding biopsy/lab results YesNo

Call you at your place of employment ? YesNo

Discuss your condition with any household member YesNo

If YES, whom

Relationship

Patient Name*:

Email*:

Patient Signature*:

Date*:

Patient or Guardian Signature:
(if patient is under 18)

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