I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan, and direct my treatment and follow-up among the multiple health care providers who may be involved in that treatment directly, indirectly and by delivery.

• Obtain payment from third-party payers.

• Contact normal health care operations such as quality assessments and physician certifications.

I acknowledge that I have received your Notice Of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization at any time at the address to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

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