F:ast Ride Medical ItacSolo*, PI.I.0

F:ast Ride Medical ItacSolo*, PI.I.0 Sites cis D. Wolff M.D. Ph.D. 170 E nr• fit_ Nen York, NV 10073 HIPAA PRIVACY NOTICE • I acknowledge that I have been given a copy of the Practices - HIPAA Privacy Notice" which describes the Practice's obbgations to ensure the privacy of ay health information. The HIPAA Privacy Notice also describes how the Practice may use and disclose my health information for treatment, payment and health care operations. I know that I have the right to review the Practice's NIPAA Privacy Notice and to ask questions about It. I understand the Practice is required to maintain the privacy of my wale, information In accordance with the terms of its rlIPAA Privacy Notice. • I further acknowledge that the Practice can change its HIPAA Privacy Notice in the future, and 'helicon receive a copy of the Practices current Privacy Notice at any tante by contacting the Privacy Officer. • I understand that I have a right to request that the Practice restrict its uses and disclosures of my health information for treatment, payment, or health care operations. If my restrictions are accepted by the Practice, these restrictions will be binding on the Practice. I also understand that the Practice is not required to agree to my requested restrictions. • I RAINS 'squad any restrictions on the Practice's use or disclosures of my health Information for treatment. payment or health care operations. • I de request specific restrictions, as listed below, on the Practice's use or disclosures of my hearth information for treatment, payment or health care operations. • By signing this form, I consent to the Practice's use and disclosure of my health information for treatment, payment and healthcare operations. I understand that I have the right to revoke this consent at any time a writng, but if I do, my revocation wifi not influence any ections the Practice has eroady taken in reliance on this consent. RSORINUatI911 Jo Obtain or Release Medical Records from Medical Providers I hereby authorize East Side Medical Radiology PLLC to obtain any and all medical records spagreenfly rotated to my current condiboe from any physician, hospital, or other health care professional that has provided medical care to me in relation to my current condition in the past. I also authorize the Practice to release any and all medical records, physically or verbally, concaving ay tare to the following specified parties: Referring Physician D 0i.1r.lfle KRue€R. Insuranco Company, Medicare, Medicaid, Third Party Administrator, Managed Care Company Additional Party Name Consent Required Consent Required Relationship to Patient 4. S. Authorization to Obtain or Release Medical jnforniation to Individualfamily Members in accordance with federal government privacy rules anptitmer tad through the Healthcare Portability Act of 1906 (HIPAA). in order for your physician or staff of the Practice to discuss your condition with members of your family or other individuals that you des-gnatb we must obtain your authorization prior to doing so. In the event of a critical episode or if yOu are unable to give your authorization due to the severity of your mezdkal conditions. Ow law stipulates that these rules may be waived (Initial) I authorize the Practice to release any or all information, in any form of communication, concerning my medical care as set forth above. Patient's Signature: Print Patient's Name 0 -1E- FE- CG. N Le311E-O Date: 1- ( 1 1 ig,(;Die EFTA00313924