I consent to the use or disclosure of my personal health information by Sleep Disorders Center of
Connecticut, LLC, for the purpose of diagnosing and providing treatment to me, obtaining payment for my
health care bills, or to conduct health care operations of the practice. I understand that diagnoses or
treatment of me by the Center may be conditioned upon my consent as evidenced by my signature on this
I understand that the Center had created a Notice of Privacy Practices that provides a more complete
description of the intended uses and disclosures by the Center. I have a right to review the Center’s Notice
of Privacy Practices prior to signing this document. The Center’s Notice of Privacy Practices has been
provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected
health information that will occur in my treatment, payment of my bill, or in the performance of health care
operations of the Center.
I understand I have the right to request a restriction as to how my protected health information is used and
disclosed to carry out treatment, payment, or health care operations of the Center. The Center is not required
to agree to the restrictions that I may request. If the Center agrees to a restriction that I request, however, the
restriction is not binding on the Center.
I have the right to revoke this consent, in writing at any time, except to the extent that Sleep Disorders
Center of Connecticut, LLC, has taken any action in reliance to the consent.
My “protected health care 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 or health care clearing house. This protected health care information related to my past, present,
or future physical or mental health or condition that identifies me, or there is a reasonable basis to believe
the information may identify me.
The Notice of Privacy Practices for the Center is also provided and available to me for my review if requested
by me. This Notice of Privacy Practices also describes my rights and the Center’s duty with respect to my
protected health information.
The Center reserves the right to change the privacy practices that are described in the Notice of Privacy
Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised
copy be sent to me by mail, or asking for on at the time of my next appointment.
Signature of Patient or Personal Representative :
Name of Patient or Personal Representative :
Social Security Number :
Description of Personal Representative’s Authority :