With my consent, DermCARE Practitioners, LLC may use and disclose protected health information (PHI) about me, including diagnosis, records, examination rendered to me, and claims information, to carry out treatment, payment and healthcare operations. You have the right to review our notice before signing this consent. We encourage you to read it in full. It is available at the front desk or online at www.DermCAREPractitioners.com/new-patient-forms .
By signing this form, I understand that:
• Protected health information may be disclosed or used for treatment, payment or healthcare operations.
• The patient has the right to revoke this consent in writing at any time.