Consent to Use PHI

Acknowledgement for Consent to Use and Disclosure of Protected Health Information

Use and Disclosure of your Protected Health Information
Your Protected Health Information will be used by The Spero Clinic Integrated Health & Wellness Center (IH&WC) or may be disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of the offices.

Notice of Privacy Practices
You should review the Notice of Privacy Practices for a more complete description of how your Protected Health Information may be used or disclosed. It describes your rights as they concern the limited use of health information, including your demographic information, collected from you and created or received by our offices. I have received a copy of the Notice of Patient Privacy Policy.

Requesting a Restriction on the Use or Disclosure of Your Information

Notice of Treatment in Open or Common Areas
Describe and Notify private areas available upon request.

Revocation of Consent
You may revoke this consent to the use and disclosure of your Protected Health Information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.

You give permission to use and disclose your health information.