Please note that we maintain paper & electronic files that may contain private information about you that may include, but are not limited to your name, address, phone number, contact person, height & weight, diagnosis, prognosis, physician’s prescriptions, plans of services & treatment, vital signs, clinical impressions, insurance coverage(s), equipment rented & purchased from us, credit card number, dates of services, etc. We release, transfer & disclose the above information to the third parties to facilitate appropriate provision & review of services & billing for our clients of record. These files are legal documents & are also used for education, evaluating the performance of our organization, marketing & planning purposes. We have measures in place to protect patient health information as required by law. These measures include, but are not limited to, security precautions being in place in our building, billing software, transactions of data to third-parties telephonic & wireless communications, maintenance, retention, & destruction of data, etc. You have the right to amend, restrict, revoke consent to release, examine or obtain copies of the data that we have in your file & have released to others upon request. If you have questions concerning any of the above, please contact our Privacy Officer at the telephone number listed above. I have had full opportunity to read and consider of this Consent form and your Notice of Privacy Practices. I understand that, by signing this consent form. I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and healthcare operations.
As a reminder, you must stay awake for the first 10 minutes of this test!