HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) AND THE SECURITY RULE WITH NOTICE OF PRIVACY PRACTICES

Patient Consent for Use and Disclosure of Protected Health Information.

HIPAA protects the privacy and security of health information. The Security Rule protects individually identifiable health information that is created, received, maintained, and transmitted at Medical Network Colombia in electronic form. This information is referred to as electronic personal health information (e-PHI).

Medical Network Colombia maintains reasonable and appropriate administrative, technical, and physical safeguards for protecting your (e-PHI). We ensure confidentiality, integrity, and availability of all (e-PHI) created, received, maintained, or transmitted.

By checking this box, I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) I have certain rights to privacy regarding my protected health information (PHI). I understand that this information can and will be used to:

• Obtain payments.
• Conduct normal healthcare operations such as quality assessments and physicians’ certifications.
• Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.

I have the right to review the Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my health information, prior to approving by checking this consent.

I understand that Medical Network Colombia has the right to change its Notice of Privacy Practices from time to time and that I may contact them at any time to obtain a current copy of the Notice of Privacy Practices.

I understand that I have the right to revoke this consent in writing at any time. However, such revocation shall not affect any disclosures already made in reliance of my prior consent.