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I acknowledge that I have read and received a copy of the aforementioned Practice’s Notice of Privacy Practice.

PATIENT CONSENT FORM

The department of Health and Human Services has established a “Privacy Rule” to help insure that personal health care information is protected for privacy. The privacy rule was created in order to provide a standard for certain healthcare providers to obtain their patients’ consent for uses and disclosures of health information about the patient to carry out treatment, payment or healthcare operations.

As our patient we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your healthcare information.

We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may have to disclose personal health information for purposes of treatment, payment or healthcare operations. These entities are most often not required to obtain patient consent.

You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing.

Under this law we have the right to refuse treatment to you should you choose to refuse to disclose your Personal Health Information.

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