This form is an agreement between you, __________________________________________and Print Client Name Bright Future Community Health Care Services. When we examine, diagnose, treat, or refer you, we will be collecting what the law calls Protected Health Information (PHI) about you. We need to use this information to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others who provide treatment to you or need it to arrange payment for your treatment or for other business or government functions. By signing this form, you are agreeing to let us use your information here and send it to others. The Notice of Privacy Practices explains in more detail your rights and how we can use and share your information. Please read the Notice of Privacy Practices before you sign this Consent Form. In the future, we may change how we use and share your information and so may change our Notice of Privacy Practice. If we do change it, you can get a copy by contacting our office at 443-832-4526, Monday – Friday 9:00am - 5:00pm. If you are concerned about some of your information, you have the right to ask us not use or share some of your information for treatment, payment, or administrative purposes. You will have to tell us what you want in writing. Although we will try to respect your wishes, we are not required to agree to these limitations. However, if we do agree, we promise to comply with your wishes. After you have signed this consent, you have the right to revoke it (by writing a letter telling us you no longer consent) and we will comply with your wishes about using or sharing your information from that time on, but we may have used or shared some of your information and cannot change that.