Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.
The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you
have reviewed our notice before signing this consent.
The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare
operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health
Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or
By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous
usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not
The communication can be delivered by the following:
I give permission to Pediatrics of Sugar Land staff to discuss with the following listed individual(s),information reasonably deemed to be directly related to such individual’s involvement on the above referenced patients’ health care