I give this practice/clinic my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies and for health care operations.

I have been informed that I may review the practice/clinic’s “Notice of Privacy Practices” for a more complete description of uses and disclosures before signing this consent.

I understand that this practice/clinic had the right to change their privacy practice and that I may obtain any revised notice at the practice/clinic.

I understand that I have the right to request a restriction of how my protected health information is used. However, I understand that the practice/clinic is not required to agree to the requested. If the practice/clinic agrees to my requested restriction, they must follow the restriction(s).

I also understand that I may revise this consent at any time, by making a request in writing, except for my information already used or disclosed.