I, the below signed patient or their responsible party, give permission to Comlete Family Health, LLC to provide medical treatment and/or consultation to  "me" or name of patient.
The undersigned patient or responsible party (parent, legal guardian, or conservator) consents to, and authorizes services, by Complete Family Health, LLC. These services may include physical examinations, medication therapy, laboratory tests, diagnostic procedures, and other appropriate therapies.

The undersigned understands that he/she has the right to:

• Be informed of and participate in the selection of treatment modalities.
• Receive a copy of this consent.
• Withdraw this consent at any time.
• Refused any procedure or treatment
• To request to be seen or referred to another healthcare provider. 

The undersigned acknowledges and understands that: 

• Appointments must be canceled or rescheduled 24 hours prior to the scheduled appointment. 
• Missing a scheduled appointment without proper notice will incur a $25.00 fee. 
• Missing 3 scheduled appointments without proper notice within the same calendar year may cause dismissal from the practice.
• If the patient or responsible party has an Direct Primary Care Membership and fails to pay monthly membership fees and other amounts owed at the time they are due for more than 30 days (i.e., after you miss two monthly payments) your memberships will be revoked.

HIPAA Compliance

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 that 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.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such 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 operations.
• The practice reserves the right to change the privacy policy as allowed by law.
• The practice 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 the execution of this consent.