CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
SECTION A : PARENT / PATIENT GIVING CONSENT
Telephone : E-Mail :
Patient # :
SECTION B : TO THE PATIENT -- PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY
Purpose of Constent : By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment actitvities and health care operations.
Notice of Privacy Practices : You have the right to read our Notice of Privacy before you decide whether to sign this Consent. Our notice provides a description of our treatment, payment activities and health care operations, of the use and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this consent. We encourage you to read it care fully and complete before signing this consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices, if we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain changes. Those changes may apply to any of your protected health information that we may maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revision of our Notice, at any time by contacting :
Contact Persons :
Telephone : Fax :
Right to Revoke : You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. please understand the revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you ro to continue treating you if your revoke this Consent.
I , have had full opportunity to read and consider the contents of this Consent form and you Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use disclosure of my protected health information to carry out treatment, payment activities and health care operations.
Signature : Date:
If this Consent is signed by a personal representative on behalf of the parent, complete the following:
Personal Representative's Name :
Relatiionship to Patient :
REVOCATION OF CONSENT
I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and health care 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 : Date:
ACKNOWLEDGEMENT OF RECEIPT
OF NOTICE PRIVACY PRACTICES
* You may Refuse to Sign This Acknoledgement *