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Fax: 760 - 434 - 6280
Consent to Use or Disclose Information
I, _________________________________________ hereby acknowledge that I have been given a copy of the “Privacy Notice (Effective Date: April 14, 2003). THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW A PATIENT CAN GET ACCESS TO THEIR IDENTIFIABLE HEALTH INFORMATION.
I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I’ve provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon.
□ No restrictions □ I request the following restrictions to the use or disclosure of my health information:
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I have been advised by North Coast Medical Supply to read this document and to forward any questions to their Compliance Officer @ 1.800.730.9887.
_________________________________________ ________________________ Beneficiary Signature Date
_________________________________________ ________________________ North
Coast Medical Supply Representative
Date
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