With my consent, my therapist Anne G. Walker LCSW, may use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operations (TPO). Please refer to my therapist's Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent.

My therapist reserves the right to revise her Notice of Privacy Practices at any time. A revised copy may be obtained by written request to her office at 4811 Emerson Avenue Suite 101 Palatine, IL 60067.

With my consent, my therapist and her staff may call my home, cell or other designated location and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out TPO, such as insurance items or any call pertaining to my clinical care.

With my consent, my therapist and her staff may mail to my home or other designated location any items that assist the practice of carrying out TPO, such as client billing statements.

I have the right to request that my therapist's office restrict how it uses or discloses my PHI to carry out TPO. However, my therapist is not required to agree to my requested restrictions, but if she does, is bound by this agreement. By signing this form I am consenting to my therapist to the use and disclosure of my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in relaince upon my prior consent. If I do not sign this consent my therapist may decline to provide treatment to me.