I understand that as part of my healthcare, the providers of the licensed medical clinics doing business as MedSomma and its affiliates (“MedSomma”), originate and maintain health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment.  I understand that this information is utilized to plan my care and treatment, to bill for services provided to me, to communicate with other healthcare providers and other routine healthcare operations such as assessing quality and reviewing competence of healthcare professionals.  to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations.

I have received and reviewed the Professional Privacy Policy prior to signing this consent available on www.medsomma.com. MedSomma reserves the right to revise its Professional Privacy Policy at any time. 

I understand that I have the right to restrict the use and/or disclosure of my PHI for treatment, payment or healthcare operations and that MedSomma is not required to agree to the restrictions requested. 

I may revoke this consent at any time in writing except to the extent that MedSomma has already acted in reliance of my prior consent.  This consent is valid until revoked by me in writing. 

In my patient profile, MedSomma has permission to disclose PHI to a designated party listed. This will must obtain your written authorization to use your PHI for any purpose other than treatment or billing. 

I further understand that any and all records, whether written, oral or in electronic format, are confidential and cannot be disclosed without my prior written authorization, except as otherwise provided by law.