1. Permission to use and disclose my private health information:

By signing this form I give Dr.Jeffrey Robichaud permission to use/disclose my private health information for the purpose of carrying out treatment, obtaining payment for services rendered or for routine office operations related to my care.

2. Right to Refuse:

I have the right not to sign this consent. If I refuse to sign this consent, Dr. Jeffrey Robichaud will not be able to provide me with any treatment until such time that I
agree to sign. However, in the event of an emergency where Dr. Jeffrey Robichaud is required by law to render emergency care my consent is not required.

3. Right to review notice of privacy practices:

Dr. Jeffrey Robichaud has provided me with the opportunity to review the privacy practices of the office regarding the disclosure of protected health information.

4. Changes to the privacy notice: Dr. Jeffrey Robichaud may change the notice of privacy
practices as needed. I may obtain a copy of the revised practices by contacting the office
directly.

5. Right to request restrictions on use/disclosure of information:

I have the right to request that Dr. Jeffrey Robichaud restrict the use of protected health information for the purposes of treatment, payment or operations. However, I understand Dr. Jeffrey Robichaud is not required to agree to these requested restrictions. This request must be made in writing, and Dr. Jeffrey Robichaud will give a written reply to my request within 48 hours of its receipt.

6. Right to withdraw consent:

I have the right to withdraw this consent at any time. I must do so in writing. My withdrawal of consent does not impact information disclosed or used prior to the request for withdrawal. If I withdraw my consent, I understand Dr. Jeffrey Robichaud will no longer be able to provide me with treatment, unless required by law for emergency purposes.

7. Effective period: This consent is good from this date forward, unless I withdraw my consent in writing.

8. References to "I" and "me": References to "I" and "me" in this document include the

individual for whom the signing party is authorized to sign. If I am signing this consent on behalf of another person, such as a minor child, it is because I am the legal guardian, parent of agent under an active power of attorney. I acknowledge I am legally authorized to sign this consent on behalf of the individual.