When we examine, test, diagnose, treat, or refer you we will be collecting what the law calls Protected Health Information (PHI) about you. We need to use this information to decide what treatment is best for you, and to provide you with this treatment. We may need to share this information with others who provide treatment to you, need to arrange payment for your treatment, or for other business or government functions. In most cases, as defined in our Notice of Privacy Practices, your written consent will be needed to disclose your PHI.
Your PHI may include: records covered by federal rules governing confidentiality of alcohol and drug abuse treatment programs; records covered by state rules governing mental health services; and records concerning you, or your child's, diagnosis or treatment for HIV or AIDS.
By signing this form, you are agreeing to let us use your information here and to send it to others. Our Notice of Privacy Practices explains in more detail your rights, and how we can use and share your information.
If you do not sign this consent form agreeing to what is in our Notice of Privacy Practices, we cannot treat you.
In the future we may change how we use and share your information and therefore may change our Notice of Privacy Practices. If we do change it, you can get a copy from our Privacy Officer. If you are concerned about some of your information, you have the right to ask us not to use or share some of your information for treatment, payment, or administrative purposes. We require all requests to be in writing. Although we will try to respect your wishes, we are not required to agree to these limitations. However, if we do agree, we promise to do as you asked.
After you have signed this consent, you have the right to revoke it (by writing a letter to our Privacy Officer telling us you no longer consent) and we will comply with your wishes about using or sharing information from that time on but we may already have used or shared some of your information and cannot change that.
By signing below, you are confirming you have read the above and received a copy of our Notice of Privacy Practices.