PATIENT HIPAA CONSENT

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Information Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent, I authorize Medical Vein Clinic to use and disclose my protected health information (PHI) to carry out the following:

• Treatment (including direct and indirect treatment by other healthcare providers involved in my treatment)
• Obtain payment from third party payers (e.g. my insurance company)
• The day-to-day healthcare operations of Medical Vein Clinic
• I have also been informed of, and given, the right to review a secure copy of the Medical Vein Clinic Privacy Statement, which contain a more complete description of the uses and disclosure of my PHI and my rights under HIPPA. I understand that Medical Vein Clinic reserves the right to change the terms of this notice at any time and that I may contact Medical Vein Clinic at any time to obtain the most current copy of this notice.