Our notice of privacy practices information about how we may use or disclose protected health information.

The notice contains a patients rights section describing your rights under the law you ascertain that by your signature that you have reviewed our notice signing this consent.

The term of the notice may change, if so you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclose for treatment, payment or healthcare operation. We are not required to agree with the restriction, but if we do, we shall honor the agreement. The HIPAA (Health insurance portability and accountability act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication have the right to revoke this consent in writing, signed by you however, such a revocation will not be retroactive.

by signing this form ,I understand that:

protected health information may be used and disclosed for treatment, payment or healthcare operations.
the practice reserves the right to change the privacy policy as allowed law.
the practice has the right to restrict the use of information, but the practice does not have to agree to those restrictions.
the practice has the right to revoke this consent in writing at any time and all full disclosures will then case.
the practice may condition receipt of treatment upon execution of this consent.

HIPAA Compliance Agreement: Please Sign Below: *

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Questions? 412.808.0520