Our Notice of Privacy Practices explains how we use and disclose your protected health information and outlines your rights. You may review or request a copy at any time, including any updates. Please list below any individuals authorized to receive your medical or financial information. If the patient is a minor, a parent or legal guardian may receive this information.
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By opting in to text messages, I understand that message and data rates may apply, text messages may not be secure, and messages may include appointment reminders, scheduling, and limited healthcare information. I may opt out at any time by notifying the practice or replying STOP (if applicable). If I decline or opt out of text messages, I will not receive appointment reminders by text and must opt back in myself to resume messages.
By opting in to email communications, I understand that email may not be secure and messages may include appointment reminders, billing information, and limited healthcare information. If I decline email communications, I will not receive appointment reminders by email.
By signing this form, I consent to the use and disclosure of my protected health information for treatment, payment, and healthcare operations in accordance with HIPAA. I understand communication preferences are voluntary and may include limited health information. I may change or revoke my preferences at any time in writing. If I decline electronic communications, I am responsible for keeping track of my appointments and any am responsible for any applicable missed appointment or last minute (less than 24-72 hours notice based on appointment type) cancellation fees.
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.
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