HIPAA Compliance

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CONEJO PAIN SPECIALISTS MEDICAL GROUP, INC.

Practice Clinic: 3366 E. Thousand Oaks Blvd, 2nd Floor, Thousand Oaks,CA 91362
Telephone (805) 497-8616     Facsimile (805) 496-5585

Legal Service Office: 430 East Avenida de Los Arboles, Suite 101, Thousand Oaks, CA 91360
Telephone (805) 241-0151     Facsimile (805) 241-0161

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY

Consent for Purposes of Treatment, Payment and Healthcare Operations

I consent to the use or disclosure of my protected health information by Conejo Pain Specialists Medical Group, Inc., its physicians, professional and clerical staff, and independent contractors (together Conejo Pain Specialists Medical Group, Inc.)for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills, providing appointment reminders or to conduct health care operations of Conejo Pain Specialists Medical Group, Inc. I understand treatment of me at Conejo Pain Specialists Medical Group, Inc. may be conditional upon my consent as evidenced by my signature in this document.

I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment, or healthcare operations of Conejo Pain Specialists Medical Group, Inc. Conejo Pain Specialists Medical Group, Inc. is not required to agree to the restrictions that I may request. However, if Conejo Pain Specialists Medical Group, Inc. agrees to a restriction that I request the restriction is binding on Conejo Pain Specialists Medical Group, Inc.

I understand that I have the right to request:

• Access to my protected health information
• Amendments of my protected health information
• Confidential communications
• An accounting of disclosures of my protected health information

I have the right to revoke this consent, in writing, at any time, except to the extent that Conejo Pain Specialists Medical Group, Inc. has taken actions in reliance on this consent.

My Protected Health Information? is individually identifiable health information, including my demographic information. This information is collected from me and created or received by my physician, another healthcare provider, a pharmacy, a health plan, my employer or a healthcare clearinghouse. This Protected Health Information relates to my past, present, or future physical or mental health or condition, and identifies me, or there is a reasonable basis to believe the information may identify me.

I understand that it is sometimes necessary to post/say my name for care and efficiency and to allow the healthcare team to locate me during my stay. I give permission to have my name posted/said for these reasons.

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