PLEASE READ CAREFULLY: I understand my medical records are confidential. I understand that by signing a consent form I am allowing my medical information to be released upon the request of my insurer for the purpose of Health Care Operations {including, but not limited to, provider review, claims payment and assurance.} I also understand that I may revoke this consent by written request, at any time, with this office. If revoked, all parties understand that all information released prior to being notified of such revocation was made with my consent.

I understand that I have a right to restrict the disclosure of specific information in my medical records if I request such restriction in writing, I also understand that request for restriction may be denied if the information is required for Health Care Operations.