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Our Notice of Privacy Practices provides information about how
we may use and disclose protected health information about you.
The Notice contains a Patient Rights section describing your
rights under the law. You have the right to review our Notice
before signing this Consent. The terms of our Notice may change.
If we change our Notice, you may obtain a revised copy by
contacting our office.
You have the right to request that we restrict how protected
health information about you is used or disclosed for treatment,
payment or health care operations. We are not required to agree
to this restriction, but if we do, we shall honor that
agreement.
By signing this form, you consent to our use and disclosure of
protected health information about you for treatment, payment
and health care operations. You have the right to revoke this
Consent, in writing, signed by you. However, such a revocation
shall not affect any disclosures we have already made in
reliance on your prior Consent. The Practice provides this form
to comply with the Health Insurance Portability and
Accountability Act of 1996 (HIPAA).
The patient understands that:
- Protected health information may be disclosed or
used for treatment, payment or health care
operations
- The Practice has a Notice of Privacy Practices
and the patient has the opportunity to review this
Notice
- The Practice reserves the right to change the
Notice of Privacy Policies
- The patient has the right to restrict the uses
of their information but the Practice does not have
to agree to those restrictions
- The patient may revoke this Consent in writing
at any time and all future disclosures will then
cease
- The Practice may condition treatment upon the
execution of this Consent
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DOWNLOAD PATIENT CONSENT
FORM
For quicker services at our office, please
download, print out, sign, and bring this
Patient Consent form to your first visit to our
office. Click the link below to download the
.pdf form: |
Technical Note:
Our forms use the Adobe Acrobat Plug-in to allow
patients the convenience of completing their patient
consent forms from home or work. Please
download the free plug-in from Adobe's web site if it
is not already installed on your system. |
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