The default Consent for Use or Disclosure of Health Information Form that comes with BackChart can be reviewed below.

Consent for Use or Disclosure of Health Information form

Our Privacy Pledge

We are very concerned with protecting your privacy. While the law requires us to give you this
disclosure, please understand that we have, and always will, respect the privacy of your health
information.

There are several circumstances in which we may have to use or disclose your health care information.

- We may have to disclose your health information to another health care provider or a hospital if it
is necessary to refer you to them for the diagnosis, assessment, or treatment of your health
condition.

- We may have to disclose your health information and billing records to another party if they are
potentially responsible for the payment of your services.

- We may need to use your health information within our practice for quality control or other
operational purposes such as recall notices, reminder calls, and treatment news.

Along with this consent form, you will be given a copy of our privacy notice that describes our
privacy policies in detail. You have the right to review that notice before you sign this consent form.
We reserve the right to change our privacy practices as described in that notice. If we make a change
to our privacy practices, we will notify you in writing when you come in for treatment or by mail.

Your right to limit uses or disclosures

You have the right to request that we do not disclose your health information to specific individuals,
companies, or organizations. If you would like to place any restrictions on the use or disclosure of
your health information, please let us know in writing. We are not required to agree to your
restrictions. However, if we agree with your restrictions, the restriction is binding on us.

Your right to revoke your authorization

You may revoke any of your authorizations at any time; however, your revocation must be in writing.
We will not be able to honor your revocation request if we have already released your health
information before we receive your request to revoke your authorization. If you were required to give
your authorization as a condition of obtaining insurance, the insurance company may have a right to
your health information if they decide to contest any of your claims.

I have read your consent policy and agree to its terms. I am also acknowledging that I have received a
copy of this consent form and a copy of your privacy notice (Notice of Privacy Practices for Protected
Health Information).

Patient Name: JOHN