I hereby authorize Colorado Health and Wellness to use and disclose my protected health care information to carry out my treatment, to obtain payment from insurance companies, and for healthcare operations like quality reviews.
I have been informed that I may review Colorado Health and Wellness’ Notice of Privacy Practices (for a more complete description of uses and disclosures) before signing this consent.
I understand that this practice had the right to change their privacy practices and that I may obtain any revised notices from Colorado Health and Wellness.
I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that Colorado Health and Wellness is not required to agree to the request. If Colorado Health and Wellness agrees to my requested restriction, they must follow the restriction(s).
I also understand that I may revoke this consent at any time, by making a request in writing, except for information already used or disclosed.