Please read entire document before signing. Please ask questions if anything is unclear.

Acknowledgement for Consent to Use and Disclosure of Protected Health Information

Use and Disclosure of your Protected Health Information

    Your Protected Health Information will be used by Youngstown Spine & Disc Inst. Inc. or  may be disclosed to others for the purposes of treatment, obtaining payment or supporting the day-to-day health care operations of this office.

Notice of Privacy Practices

    You should review the Notice of Privacy Practices for a more complete description of how your Protected Health Information may be used or disclosed. It describes your rights as they concern the limited use of health information, including your demographic information, collected from you and created or received in this office. You may review the Notice prior to signing this consent. You may request a copy of the notice at the front desk.

Requesting a Restriction on the Use or Disclosure of Your Information

• You may request a restriction on the use or disclosure of your Protected Health Information
• This office may or may not agree to restrict the use or disclosure of your Protected Health Information
• If we agree to your request, the restriction will be binding to the office. Use or disclosure of protected information in violation of a written agreement upon restriction will be a violation of the federal privacy standards.

Revocation of Consent

    You may revoke this consent to the use and disclosure of your Protected Health Information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.