PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.
PURPOSE OF CONSENT: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.
NOTICE OF PRIVACY PRACTICES: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of the following; treatment, payment activities, healthcare operations, uses and disclosures we may make of your protected health information. It also includes other important matters about your protected health information.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
You are entitled to a copy of this consent after you sign it. One will be made available for you upon request. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting our office.
RIGHT TO REVOKE: You will have the right to revoke this Consent at any time by giving written notice submitted to our office manager. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent prior to receiving your revocation. We have the option to decline or continue treatment if you revoke this Consent.
SIGNATURE: