I hereby give my consent to my Medical Provider at S&K Primary Care, LLC, and his/her designated healthcare provider for the evaluation, diagnostic (s), testing, and treatment. I understand I may request and receive information on the specific affiliation (s) of any healthcare provider I encounter during my care.

I understand that protected health information (PHI) may refer to medical or health information, including prognosis, psychological or mental illness, prescription, laboratory, and other medical results, tests or diagnosis.

I give my consent for the release of my PHI for the purpose of treatment, payment, and other relevant healthcare operations.

I understand that I have the right to discuss all of my medical treatment (s) with my provider. I have the right to refuse any procedure or treatment.

I understand that I shall be financially responsible for all treatments and services provided by S&K Primary Care, LLC. I understand that S&K Primary Care, LLC will not submit a claim for insurance benefits to pay for the care I receive. I understand that if I have insurance, it is my responsibility to contact my insurance company for reimbursement of services paid for.

I hereby give my consent to the taking of my photograph for the purpose of identification for treatment if necessary, or for the purpose of identity for records and/or payment purposes. These photographs shall be kept by S&K Primary Care, LLC for the incidental purpose as it may be deemed necessary for the processing of my information.

I hereby declare that I am of legal age and mentally capable of giving my consent. I have had the opportunity to ask questions and clarifications, and by which I have received answers to my satisfaction.

The notice of Privacy Practices provides information on how we use or disclose protected health information.

This notice describes your rights under the law. By signing this agreement, you acknowledge that you have reviewed the notice before signing your consent.

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 Health Insurance Portability and Accountability Act of 1996 (HIPAA), allows for the use of 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 publications. 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 operations.
• The Practice has the right to change the Privacy Police as allowed by law.
• The Practice has the right to restrict the use of information, but the Practice does not have to agree to those restrictions.
• I have 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.