David Schechter, M.D.

David Schechter, M.D.

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Patient Name *

With my consent, David Schechter, MD may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO).

Please refer to David Schechter, MD's Notice of Privacy Practices for a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. David Schechter, MD reserves the right to revise its Notice of Privacy Practices anytime.

A revised Notice of Privacy Practices may be obtained by forwarding a written request to David Schechter, MD Privacy Officer at his practice in West LA.

With my consent, David Schechter, MD may call my home or other designated location and leave a message on voice mail in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others.

With my consent, David Schechter, MD may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements.

With my consent, David Schechter, MD may e-mail to any email address I provide messages that assist the practice in carrying out TPO, such as lab results and patient statements. I have the right to request that David Schechter, MD restrict how it uses or discloses my PHI to carry out TPO.

However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by said agreement.

Patient Signature * Date * Name of Legal Guardian, if applicable