Our Notice of Privacy Practices provides information about how we use or disclose protected health information.

The notice contains a patient's rights section describing your rights under the law.  You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of this 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 disclosed for treatment, payment, or healthcare operations.  We are not required to agree with this restriction, but we shall honor this 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.

You have the right to revoke the consent in writing, signed by you.  However, such revocation will not be retroactive. 

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