I understand that it is my obligation to inform this office of any changes in the patient's current medical/dental conditions as they develop.
Section A: Person giving consent
I, Type a label have had full opportunity to read and consider the contents 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 our treatment, payment activities and health care operations.
Signature: Signature Date: Date If this Consent is signed by a personal representative on behalf of the patient, complete the following:
Personal Representative's Name: Type a label
Relationship to Patient: Type a label YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOUR SIGN IT. Include completed consent in the patient’s chart.
REVOCATION OF CONSENTI revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations.I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my Consent.Signature: Signature Date: Date
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