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Consent for Purposes of Treatment, Payment and Healthcare Operations

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I, patient, consent to the use or disclosure of my protected health information by Mehdi K. Mazaheri. MD, PC for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills, or to conduct health care operations of Mehdi K. Mazaheri. MD, PC. I understand that diagnosis or treatment of me by Dr. Mehdi Mazaheri may be conditioned upon my consent as evidenced by my signature on this document.

I understand I have the right to request a restriction as to how my protected health information is used of disclosed to carry out treatment, payment or healthcare operations of the practice. Mehdi K. Mazaheri. MD, PC is not required to agree to restrictions that I may request. However, if Mehdi K. Mazaheri. MD, PC agrees to a restriction that I request, the restriction is binding on Mehdi K. Mazaheri. MD, PC and Dr. Mehdi Mazaheri.

I have the right to revoke consent, in writing at any time, except to the extent that Dr. Mehdi Mazaheri or Mehdi K. Mazaheri. MD, PC has acted 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, a health plan, my employer or a health care clearing house. This protected health information relates to my past, present, and future physical or mental health condition and identifies me, or there is a reasonable basis to believe that information may identify me.

I understand I have a right to review Mehdi K. Mazaheri. MD, PC Notice of Privacy Practices prior to signing this document. The Mehdi K. Mazaheri. MD, PC Notice of Privacy Practices has been provided to me. The Notice of Privacy Practice’s 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 Mehdi K. Mazaheri. MD, PC. The Notice of Privacy Practices also describes my rights and the Mehdi K. Mazaheri. MD, PC duties with respect to my protected health information. Mehdi K. Mazaheri. MD, PC 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 accessing the Mehdi K. Mazaheri. MD, PC website, calling the office, and requesting a revised copy to be sent in the mail or at my next appointment.

pat_sign  Date: pat_date

Signature of Patient or Auth’d Representative       

auth_name

Name of Auth’d Representative (if applicable)

witness_sign  Date: witness_date

Signature of Witness