Celebration Obstetrics and Gynecology
a medical practice dedicated to women’s health
410 Celebration Place, Ste 208 Celebration, Florida 34747
Telephone 407-566-2229 Fax 407-566-2499
2209 North Boulevard West Ste C Davenport, Florida 33837
Telephone 863-424-4321 Fax 407-566-2499
Our notice of Privacy Practices provides information about how we may use and release protected health information about you. You have the right to review our Notice before signing this form. As provided in our Notice, the terms of our Notice may change. If we change our Notice, you may obtain a revised copy by writing our practice or requesting a copy from our front desk staff. You have the right to request that we restrict how protected health information about you is used or released for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement.
By signing this form, you consent to our use and release of protected health information about you for treatment, payment, and health care operations as described in our Notice. You have the right to revoke this consent, in writing, except where we have already made releases in reliance on your prior consent.