East Side II Itau i'1.1.(' ?Hest% 1). Wolff 111.1). l'Ii.1). 170 K n- St., Nen I (irk %I 100 7:$ HIPAA PRIVACY NOTICE • I acknowledge that I have been given • copy el the Pratte:a 'HIPAA Privacy Notice which describes the Practices Obligations to ensure the privacy of my Stith Inlorrnatban. The HIPAA Privacy Notice also describe* how the Practice may use and disclose my health information for treebnent PaYannt and health care operations. I knew that I have the right to renew the Practices/URSA Privacy Notice and to ask questions about It. I understand the Practice is required to maintain the privacy of my health information in accordance with the terms of its HIPAA Privacy Notice. • I further acknowledge that the Practice can change its HIPAA Privacy Notice In the future. and that I can receive a copy of the Practice's current Privacy Notice at any time by contacting the Privacy Offcer. • 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 operabons. If my restrictions are acceptant 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. • Ids not request any restrictions on the Practices use or disclosures of my health Information for treatment, payment or health care operations. T'; (initial). • I gig request speCIfiCtilritrictlorts, as fisted below, on the Practice's use or disclosures of my health information for treatment, payment or health Care operations. • By signing this lore'.I consent to the Practice's use end disclosure of my health informationfor treatment. payment and healthCare operations. I understand that I have the right to revoke this consent at any time d writing, but d I do, my revocation win not influence any actions the Practice hat ready taker in reliance on this consent Au SI aption to Obtain or Release Medical Records from Medical Provident I hereby authorize East Side Medical Radiology PL LC to obtain any and ail medical records specifically related to my current condition from any physician, hospital, or other head., care professional that has provided medical care to me in relation to my current condition In the peat. I also authorize the Practice to release any and all medical records. physically or verbally, concerning my care to the following specified parties: Referring Physician Da. ei ...-deplixet. KgmeeK Consent Required Insurance Company, etedirare, Modleekt, lltird Party Administrator, Managed Care Company Consent Required Additions Party Mame Relationship to Patient 1• 2. 3. 4. lk Authorization to Obtaintor Reins* Medical Information to Individualtram_gv Members In accordance with Federal government privacy rules I mpierrien led through the Healthcare Portability Act of 1996 (HIPAA), in order fee your physician or staff of the Practice to discuss your condition with members of your I amuy or other individuals that you despnate, we must obtain your authorization prier to doing so. In tho event of a critical episode or d you are unable to give your authorization due to the Seventy o91 your medical conditions, the law stipulates that these rules may be waived (initial) I authorize the Practice to release any or all Information, In any form of communication, condommM my medical cam es set forth above. /,--- ...,.....------- Patient's Signature-- I Print Patient's Name 5;- FT:: Ai *N cran?-it.1 Date: :ThtNI - I 86)-01S) EFTA00313932