Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.
The notice contains a patient’s rights section describing your rights under the law. You ascertain by your signature, that you have reviewed our notice before signing this consent.
The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.
By signing this form, you consent to our use and disclosure of your protected healthcare information. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
By signing this form, I understand that:
· Protected health information may be disclosed or used for treatment, payment, or healthcare operators.
· The patient has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
· The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
· The practice may condition receipt of treatment upon execution of this consent.