HIPAA Acknowledgement and Consent

I understand that I have certain rights to privacy regarding my protected health information (PHI). These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize St Croix Therapy, Inc. (SCT) to use and disclose my PHI to carry out treatment, obtain payment from third party payers and complete day‐to‐day healthcare operation. I have also been informed of SCT’s Notice of Privacy Practices which is available to me in the clinic, on the SCT website and per my request a copy can be printed for me. I understand that the Notice of Privacy Practices contains a more complete description of the uses and disclosures of my PHI and my rights under HIPAA. I understand that SCT reserves the right to change the terms of this notice from time to time and that I may contact SCT at any time to obtain the most current copy of this notice. I understand that I have the right to request restriction on how my PHI is used and disclosed to carry out treatment, payment, and health care operations, but that SCT is not required to agree to my request. However, if SCT does agree, they are then bound to comply with the request. This acknowledgement and consent is good for 1 year from the date signed. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected. Additionally, I understand that I must complete an Authorization for Release of Information in addition to this form.