Consent to Use and/or Disclose Protected Health Information for Purposes of Treatment, Payment and Healthcare Operations

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As a condition of providing treatment to you, Comprehensive Mental Health Services (CMHS) requests your consent to collect, use and disclose protected health information about you to facilitate treatment, payment and healthcare options. You may revoke this consent at any time by notifying Comprehensive Mental Health Services in writing, except to the extent that Comprehensive Mental Health Services has taken action on reliance of your consent. Please refer to the Notice of Privacy Practices for Protected Health Information ("Privacy Notice") for a more complete description of the uses and disclosures that Comprehensive Mental Health Services may make of your protected health information. Please review the Privacy Notice prior to signing this consent. Comprehensive Mental Health Services reserves the right to change its privacy practices described in this Privacy Notice; in accordance with law, the terms of the Privacy Notice may change. At any time, you may obtain a copy of the current Privacy Notice and any revised notice. You have the right to request that Comprehensive Mental Health Services restrict the manner in which your protected health information is used or disclosed to facilitate treatment, payment or healthcare operations. However, Comprehensive Mental Health Services is not required to agree to such requested restrictions. When Comprehensive Mental Health Services agrees to a requested restriction, Comprehensive Mental Health Services will honor the request and it will be binding.

By signing below, I acknowledge that I have received a copy of the Notice of Privacy Practices. Also, by signing below, I consent to the use and disclosure by Comprehensive Mental Health Services, its workforce and its business associates of my protected health information to facilitate treatment, payment and healthcare options.

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