By signing this form, you consent to our use & disclosure of protected health information about you, for your treatment, payment and healthcare operations. It is your right to request that we restrict how protected health information about you is used or disclosed for treatment, payment and healthcare operations.

 

We are not legally obliged to agree to your restriction but where we agree, we are bound by our agreement. You have the right to revoke this consent in writing, except where we’ve already made disclosures whilst relying on your prior consent.

 

Please refer to our notice of Privacy practices for information on how we may use & disclose your protected health information. It is your right to review this policy before signing this form.

 

 

Patient signature:                                                                                                                            Date:

 

 

 

 

 

Parent or guardian:                                                                                                                          Date:

 

 

 

 

 

Witness signature:                                                                                                                            Date: