FORM - 4
Tapan K. Chaudhuri, M.D.
CONSENT FOR THE USE AND/OR DISCLOSURE OF
INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION
FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS
(Patient's full name)_______________________________________________________________________
(Patient's address)________________________________________________________________________
(Patient's date of birth and/or SS#)____________________________________________________________
 
I understand that as part of my healthcare, Tapan Chaudhuri, M.D. originates and maintains health records describing my health history, symptoms, examinations, test results, diagnoses, procedure codes, and treatment plans. I understand that this information serve as :
 
a basis for care and treatment plan
a means of communication among other health professionals who contribute to my care
a source of information for applying diagnosis and procedure information to my bill
a means by which a third party payer can verify that services billed were actually performed
 
I understand and have been provided with a Notice of Health Information Practices that provides a more complete description of information uses and disclosures. I uderstand that I have the right to review Notice of Health Information Practices prior to signing the consent. I understand that Tapan Chaudhuri, M.D. reserves to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I have provided. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment or healthcare operations or obtain payment and that Tapan Chaudhuri, M.D. is not require to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that Tapan Chaudhuri, M.D. has already taken action in reliance thereon.
 
I request the following restrictions to the use or disclosure of my health information :
___________________________________________________________________________________________________
___________________________________________________________________________________________________
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