Consent to Disclosure of Protected Health Information

I consent to the use or disclosure of my protected health information by:

BECKER ENTERPRISES, LLC/BECKER HEARING CENTER

As provider for the purposes of diagnosing or providing hearing care and treatment to me.

I understand that diagnosis or treatment of me by Provider may be conditioned upon my consent as evidenced by my signature on this document (provided at time of visit).

I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out hearing care and treatment. Provider is not required to agree to the restrictions that I may request. However, if Provider agress to a restriction that I request, the restriction is binding on Provider.

I have the right to revoke this consent, in writing, at any time, except to the extent that Provider has taken action in reliance on this consent.

My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer, a health care clearing house, or health care software for contacting me, via email, phone call, postal mail. This protected health information relates to my past, present, or future physical and/or mental health or condition, and identifies me, or there is a reasonable basis to believe the information may identify me.