By signing below I certify:
1. That I have read or have had this consent read to me.
2. That I was given an opportunity to ask questions.
3. That all my questions were answered to my satisfaction, and
4. That I understand this consent and accept its terms and conditions.
Notice of Privacy Practices: I understand I have a right to review LaSalle County Health Department’s Notice of Privacy Practices prior to signing this document. LaSalle County Health Department’s Notice of Privacy Practices has been offered to me. The Notice of Privacy Practices described the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of LaSalle County Health Department. This notice of Privacy Practices also describes my rights and LaSalle County Health Department’s duties with respect to my protected health information.