CONSENT FOR RELEASE OF INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS I,_____________________________hereby authorize Westchester Gastroenterology Associates, P.C. to use and/or disclose my health information which specifically identifies me or which can reasonably be used to identify me to carry out my treatment, payment and health care operations. I understand that while this consent is voluntary, if I refuse to sign this consent, Westchester Gastroenterology Associates, P.C. can refuse to treat me. I have been informed that Westchester Gastroenterology Associates, P.C. has prepared a privacy notice ("Notice") which more fully describes the uses and disclosures that can be made of my individually identifiable health information for treatment, payment and health care operations. I understand that I have the right to review such Notice prior to signing this consent. I understand that I may revoke this consent at any time by notifying Westchester Gastroenterology Associates, P.C. in writing, but if I revoke my consent, such revocation will not affect any actions that Westchester Gastroenterology Associates, P.C. took before receiving my revocation. I understand that Westchester Gastroenterology Associates, P.C. has reserved the right to change his/her privacy practices and that I can obtain such changed notice upon request. I understand that I have the right to request that Westchester Gastroenterology Associates, P.C. restricts how my individually identifiable health information is used and/or disclosed to carry out treatment, payment or health operations. I understand that Westchester Gastroenterology Associates, P.C. does not have to agree to such restrictions, but that once such restrictions are agreed to, Westchester Gastroenterology Associates, P.C. must adhere to such restrictions.
Westchester Gastroenterology Associates, P.C.
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