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 any treatment to you. We may also share this information with others who provide treatment to you or need it to arrange payment for your treatment or for other business or government functions. By signing this form, you are agreeing to let us use your information and send it to others. The Notice of Privacy Practices explains in more detail your rights and how we can use and share your information. Please read this before you sign this consent form.
We are required by law to tell you that: 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 have to change how we use and share your information and so may change our Notice of Privacy Practices. If we have to change it, you can get a copy from us.
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. You will have to tell us what you want in writing. Please understand, we are not required to agree to or honor, in any way, these limitations. However, if we do agree, we promise to comply with your wish.
After you have signed this consent, you have the right to revoke it (by writing a letter telling us you no longer consent) and we will comply with your wishes about using or sharing your information from that time on, but we may already have used or shared some of your information and cannot change that.
