TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS I consent to the use or disclosure of my protected health information by Tagaloa-Tulifau Foot and Ankle Center, Inc. for the purpose of diagnosing or providing treatment for my health care bills or to conduct health care operations of Tagaloa-Tulifau Foot and Ankle Center, Inc. I understand that diagnosis or treatment of my by Dr. Mafutaga S. Tagaloa-Tulifau, D.P.M. may be conditioned upon my consent as evidence by my signature on this document. I understand that I have the right to request a restriction as how my protected health information is used or disclosed to carry out treatment, payment or health care operations of the practice. Tagaloa-Tulifau Foot and Ankle Center Inc. is not required to agree to all restrictions that I request. However, If Tagaloa-Tulifau Foot and Ankle Center Inc. agrees to a restriction that I request, the restriction id binding on Tagaloa-Tulifau Foot and Ankle Center, Inc. and Dr. Mafutaga S. Tagaloa-Tulifau, D.P.M. I have the right to revoke this consent, in writing, at any time, except that Dr. Mafutaga S. Tagaloa-Tulifau, D.P.M. or Tagaloa-Tulifau Center Inc. has taken action in reliance to 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 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 that I have the right to review Tagaloa-Tulifau Foot and Ankle Center's Notice of Practice prior to signing this document. Tagaloa-Tulifau Foot and Ankle Center's Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices described the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or my bills or in the performance of health care operations of Tagaloa-Tulifau Foot and Ankle Center Inc. The Notice of Privacy Practices also describes my rights and duties of Dr. Mafutaga S. Tagaloa-Tulifau, D.P.M., with respect to my health information. Tagaloa-Tulifau Foot and Ankle Center, Inc. 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 be sent in the mail for one at the time of my next appointment.
Date: ________________________________________ Note: If accomplished by a representative fill in the following:
Signature Above Printed Name of Representative: ____________________________
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