HIPPA CONSENT

I hereby give permission and authorize Dr. Anthony Blasco and/or UB Well Center, (henceforth, The Practice), his Staff and duly authorized agents to release, use and/or share my confidential health information to my attorney, insurance carrier, and to use my confidential health information as necessary on order to obtain payment for services rendered.

I understand that my file will be handled by the practice and used for documentation purposes in open assessment areas.  The Practice is hereby authorized to use my protected health information to provide assessments to me and to obtain payment for that assessment in order to carry out its health care operations.

The Practice reserves the right to change its Privacy Notice in accordance with applicable law.

I understand and consent to the following appointment reminders that will be used by The Practice: personal phone calls to home, cell or work, emails, fax, text, social media, and mail.  I agree that the practice may leave a message to any person or message machine that should answer the phone.

I understand that I have a right to request that The Practice restrict how my personal information is used or disclosed.  These requests are listed below.

I understand that this Consent is valid for seven years.  I also understand that I may revoke this consent in writing at any time for future transactions.

I have read and understand the terms of this authorization and I have had an opportunity to ask questions about the use and disclosure of my health information.