I hereby give my consent for Dayton Internal Medicine Clinic to use and disclose protected health information (PHI) about me to carry out Treatment, Payment and Healthcare Operations. (The Notice of Privacy Practices provided by Dayton Internal Medicine Clinic, describes such uses and disclosures more completely and is continually posted in the waiting room at Dayton Internal Medicine Clinic.)

I have the right to review the Notice of Privacy Practices prior to signing this consent. Dayton Internal Medicine Clinic reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by fmwarding a written request to Office Staff at Dayton Internal Medicine Clinic.

With this consent, Dayton Internal Medicine Clinic, may call my home or other alternative location and leave a message on voice mail or in person to who answers the phone, in reference to any items that assist the practice in carrying out Treatment, Payment and Healthcare Operations, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.

With this consent, Dayton Internal Medicine Clinic, may mail to my home or other alternative location any items that assist the practice in carrying out, Treatment, Payment and Healthcare Operations, such as appointment reminder cards and patient statements.

With this consent, Dayton Internal Medicine Clinic may e-mail to my home or other alternative location any items that assist the practice in carrying out Treatment, Payment and Healthcare Operations, such as appointment reminder cards and patient statements. I have the right to request that Dayton Internal Medicine Clinic restrict how it uses or discloses my PHI to carry out Treatment, Payment and Healthcare Operations. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I hereby acknowledge I received, read and understand the Notice of Privacy Practices of Dayton Internal Medicine Clinic, which sets forth the ways in which my personal health information may be used or disclosed by Dayton Internal Medicine Clinic and outlines my rights with respect to such information. I am consenting to allow Dayton Internal Medicine Clinic, to use and disclose my PHI to carry out Treatment, Payment, and Healthcare Operations.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Dayton Internal Medicine Clinic, my decline to provide treatment to me.