I understand that as part of my health care, Current Medical Technologies, Inc. (C MT) originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results. diagnoses, treatment and any plans for future care or treatment. I understand that this information serves as:
- A basis for planning my care and treatment.
- A means of communication among the many health professionals who contribute to my care.
- A source of information for applying my diagnosis, treatment and medical device information to my bill.
- A means by which a third-party-payer can verify that products billed were actually provided, and
- A tool for routine health care operations such as assessing the quality of services and products.
I understand and have been provided with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
- The right to review the notice prior to signing this consent,
- The right to object to the use of my health information for directory purposes, and
- The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment. or health care operations.
I understand that CMT is not required to agree to the restrictions requested. I understand that may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent. this organization may refuse to provide medical device(s) as permitted by Section 164.506 of the Code of Federal Regulations.
I further understand that C MT reserves the right to change their notice and practices prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should we change our notice, we will provide a copy of any revised notice.
