SECTION B: TO THE PATIENT—PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.
Purpose of Consent: By signing this form, you will consent to Radiant Recovery & Wellness Registered Nurses, PLLC (“RRN”) use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations (the “Consent”) by RRN.
Notice of Privacy Practices: You have the right to read RRN’s Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice of Privacy Practices provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.
RRN may leave voicemails and send text messages, email or mail to the contact information provided above regarding my appointments, treatment or other protected health information related to my care with RRN.
Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed below. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.