Libertyville Longevity and Light Center (LLnLC) is committed to protecting your health information and complying with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This consent form explains how we may use and disclose your Protected Health Information (PHI) as part of your care.
Use and Disclosure of Your Information
By signing this form, you consent to LLnLC’s use and disclosure of your PHI for the following purposes:
- Treatment: Coordination and management of your care.
- Payment: Billing and payment processing through your provider or health plan.
- Healthcare Operations: Internal operations such as quality assessment, staff training, and administrative purposes.
Your Rights
You have the right to:
- Review our Privacy Policy before signing this consent.
- Request restrictions on how your PHI is used or shared. While LLnLC is not required to agree to all requests, we will honor any agreed-upon restrictions.
- Revoke this consent in writing at any time. Revocation will not affect disclosures made prior to your written request.
Our Responsibilities
- We are required to maintain the privacy of your PHI and follow the terms of our current Privacy Policy.
- We may update our privacy practices periodically. You may request a revised copy at any time by contacting our team.
Patient Acknowledgment
By signing this consent, you acknowledge the following:
- You understand that your health information may be used or disclosed for treatment, payment, or healthcare operations.
- You have received and reviewed LLnLC’s Privacy Policy.
- You understand your rights regarding the use and disclosure of your health information.
You understand that services may be conditioned upon your signing of this consent. If you have questions, please contact us.