Consent of Privacy Practices
I give this practice my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care opration such as quality review.
I have been informed that I may review the practice's Notice of Pravacy Practices for a more complete description of uses and disclosures before signing this consent.
I understand that this practice has the right to change their privacy practice and that I may obtain my revised notices at the practice.
I undrestand that I have the right to request a restriction of how my personal health information is used. However, I also understand that the practice is not required to agree to the request. If tne practice agree to my requested restricton, they must follow the restriction.
I also understand that I may revoke this consent at any time by making a request in writing except for information already use or disclosed.