Section B: TO PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.
Purpose of Consent: 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 operation.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices 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 health information.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change
our privacy practices, we will issue a revised notice of Privacy Practices, which will contain the changes. Those
changes may apply to any of your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by
contacting us by phone or email.
Right to Revoke: You will have the right to revoke this Consent at any time by giving us a written notice of your
revocation submitted to the Contact Person listed above. 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.
SECTION C: SIGNATURE
I have had full opportunity to read and consider the contents of this Consent and Notice of Privacy Practices. I
understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected
health information to carry out treatment, payment activities and health care operations.
