I understand that:

 

My protected health information will be included in treatment, payment, and healthcare operations.

 

Treatment: We may use or disclose your information for purposes of treating you. For example, we may disclose your information to another health care provider so that they may treat you.

 

Payment: We may use or disclose your information to obtain payment for services provided to you. For example, we may disclose information to your health insurance company to obtain payment for treatment.

 

Healthcare Operations: We may use or disclose your information for certain activities that are necessary to operate our practice and ensure that our patients receive quality care. For example, we may use information to train or review the performance of our staff or make decisions affecting the practice or its technology.

 

Other uses or disclosures include: to avoid a serious threat to your health or safety or the health or safety of others, for certain public health activities such as reporting certain diseases, or in response to a court order.

 

Your rights regarding your protected health information: I have the right to cancel this consent at any time. Cancellation will begin from the date I cancel my consent and will continue indefinitely. I understand that my consent cannot be revoked from past dates or events. I understand that Miro Health’s standard form of communication and contact is email, with occasional contact by telephone or video chat. While I have the right to request to communicate with Miro Health using an alternative to email, I understand that if I would prefer standard communication by phone, paper mail, or another format, Miro Health may not be able to accommodate my preference.

 

I may inspect and obtain a copy of records that are used to make decisions about my care or payment for my care, including an electronic copy. Miro Health may charge me a cost-based fee for providing my records and may deny my request under limited circumstances, e.g., if it is determined that disclosure may result in harm to myself or others.

 

While I have the right to restrict how my protected health information is used and disclosed for treatment, payment or healthcare operations, I am aware that Miro Health is not legally required to agree with my requested restriction.

 

By checking this box, I am indicating my agreement and consent for Miro Health to use and disclose my protected healthcare information in the course of my care and treatment.