Purpose of Consent: By signing this form, you will
consent to our use and disclosure of your protected health information to carry out treatment,
payment activities and healthcare operations.
Notice of Privacy Practices: You have the right to
read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice
provides a description of our treatment, payment activities, healthcare operations, of the uses
and disclosures we may make of your protected information and of other important matters about
your protected health information. You may request to see a copy of our Notice of Privacy
Practices.
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 the changes. Those changes may apply
to any of your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices,
including any revisions of our notice, at any time by contacting: