Acknowledgement of Receipt of Notice of Privacy Practice

You have the right to read our Notice of Privacy Practice before you decide whether to sign this consent. Our Notice 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 heath information. We encourage you to read it carefully.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practice. If we make changes we will issue a revised Notice of Privacy Practices. Those changes may apply to any of your protected health information that we maintain. You may contact us during business hours to obtain a co pay.

You may refuse to sign this acknowledgment

I have received a copy of this office’s Notice of Privacy Practices

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

For Office Use Only

Consent for Use and Disclosure of Health Information

By signing this form you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation. Please understand that revocation of this Consent will not affect any action we took in reliance of 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.

I have had full opportunity to read and consider the contents of this Consent Form and your Notice of Privacy Practices. I understand that by signing this Consent form, I am giving my consent to use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

You are entitled to a copy of this Consent after you sign it.