In general, the HIPAA Privacy Rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home. The patient may revoke or change this authorization at any time with a written request.

In a further effort to protect your health information and the confidentiality of you healthcare, we ask that you designate below to whom the physicians and staff at Neurology Consultants of Nebraska, P.C. may discuss your healthcare and scheduling needs as well as billing issues that may arise.

At any time you may revoke or terminate this authorization by submitting a written revocation to Neurology Consultants of Nebraska, P.C. However, your written revocation will not affect any disclosures of your medical information that the person(s) and/or organization(s) listed above have already made, in reliance of this authorization, before the time you revoke it.