Section B: To the 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, payments activities and healthcare operations.
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 provided a description of our treatment, payment activates, and healthcare operations, of the uses and discosures we may make of your protected copy of our notice accompanies this consent. We encourage you to read it carefully completely before signing this consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our 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:
1720 Destiny Lane, Bowling Green Ky, 42104
Telephone: 270-842-3554 Fax: 270-781-4644
(You are entitled to a copy of this consent after you sign it)