Consent for Purposes of Treatment, Payment and Healthcare Operations

I consent to the use or disclosure of my protected health information by Cisca Pulmonary and Critical Care for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Cisca Pulmonary and Critical Care.

I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or health care operations of the practice.  Cisca Pulmonary and Critical Care is not required to agree to the restrictions that I may request.  However, if Cisca Pulmonary and Critical Care agrees to a restriction that I request, the restriction is binding on Cisca Pulmonary and Critical Care and Dr. Alex Vazquez.  I have the right to revoke this consent, in writing, at any time, except to the extent that Dr. Alex Vazquez, or Cisca Pulmonary and Critical Care, and have taken action in reliance on this consent.

My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider or hospital (including all departments of such), a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I understand I have a right to review Cisca Pulmonary and Critical Care's Notice of Privacy Practices prior to signing this document.  The Cisca Pulmonary and Critical Care's Notice of Privacy Practices will be provided to me upon request.  It is also posted in the waiting room and exam rooms for my information.  The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Cisca Pulmonary and Critical Care.  The Notice of Privacy Practices also describes my rights and the Cisca Pulmonary and Critical Care's duties with respect to my protected health information.  Cisca Pulmonary and Critical Care reserves the right to change the privacy practices that are described in the Notice of Privacy Practices.  I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy.

____________________________________________________________
PRINT NAME (Last, First, Middle)         

_____________________________________		_____________________________
Patient’s Signature						Date

_____________________________________		_____________________________
Signature of Legal Guardian					Date