ACKNOWLEDGEMENT OF PRIVACY PRACTICES
Notice to Patient:
We are required to provide you with a copy of our Notice of Privacy Practices which states how we may use and/or disclose your health information. A patient copy of the notice is available in the waiting area. If you would like a copy please notify the front desk. Please sign this form to acknowledge that you understand the location of this notice. You may refuse to sign this acknowledgement, if you wish.
CONSENT FOR USE/DISCLOSURE OF HEALTH INFORMATION
By signing this form, ou grant us consent to use and disclose your prtected health care information for the purposes of treatment, various activities associated with payment and health care operations. Our Notice of Privacy Practices provies more details on our treatment, payment activities and health care operations. If there is not a copy of this notice accompanying this consent form, please ask for one. We encourage you to read it since it provides the details on how information about you may be used and/or disclosed, and describes certain rights you have regarding your health care information.
As stated in our Notice of Privacy Practices, we reserve the right to change our privacy practices. If we should do so, we will issue a revised notice. Since revisions may apply to your health care information, you have a right to receive a copy by contacting our privacy officer.
You have a right to revoke your consent by giving written notice to our Privacy Officer. The revocation will not affect actions that were already taken in reliance upon this consent. You should also understand that if you revoke this consent, we may decline to treat you.
You are entitled to a copy of this consent form after have you signed it.