Patient Consent to the Use and Disclosure of Information

Washington Nephrology Associates, L.L.P. (“WNA”) obtains and maintains health information relating to my past, present or future physical or mental condition, and provision of health care or payment for health care, referred to as “Protected Health Information.”  This Protected Health Information may be used or disclosed by WNA for purposes of treatment, payment or health care operations, including, but not limited to:

• Planning for my care and treatment
• Calling me with appointment reminders and lab results
• Submitting a claim to my insurer or health plan
• Assessing the quality of care provided to me

WNA’S Notice of Privacy Practices contains a more complete description of how my Protected Health Information may be used or disclosed and how I can obtain access to this information.  I understand WNA reserves the right to change its Notice and practices and I can request a copy of its current Notice.

I understand that I have the right to request restrictions as to how my Protected Health Information may be used or disclosed by WNA.  WNA is not required to agree to my request but if WNA does agree, the requested restrictions will be binding on WNA.

I further understand that, at any time, I may revoke this consent in writing, except to the extent that WNA has already taken action in reliance on it.