I understand that as part of my or my family's healthcare, The Children’s Center for Psychiatry, Psychology, & Related Services originates and maintains paper and/or electronic 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 serves as:

• A basis for planning my care and treatment.
• A means of communication among the many health professionals who contribute to my care.
• A source of information for applying my diagnosis and other information to my bill.
• A means by which third-party payors can verify that services billed were actually provided, and
• A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

I have received a copy of the Notice of Privacy Practices for The Children’s Center detailing how my information may be used and disclosed under Federal and State law. I understand the contents of the Notice. I understand that I have the following rights and privileges:

• The right to review the Notice prior to singing this Consent.
• The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations.

I understand that as part of treatment, payment, or health care operations with The Children’s Center it may become necessary to disclose my protected health information to another entity (i.e., emergency, insurance, etc.), and I consent to such disclosure for these permitted uses, including disclosures via fax and e-mail only to appropriate parties. I fully understand and accept the terms of this Consent and acknowledge the receipt of the Privacy Notice.