Consent to Use and Disclose Your Health Information

Patient's Name *

First Name Last Name

Date of Birth *

When we examine, test, diagnose, treat, or refer you, we will be collecting what the law calls "protected health information" (PHI) about you. We need to use this information in our office to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others to arrange payment for your treatment, to help carry out certain business or government functions, or to help provide other treatment to you.

This release of information specifically includes: *

Name

Relationship

Contact Phone Number

1.

2.

3.

4.

By signing this form, you are also agreeing to let us use your PHI and to send it to others for the purposes described above. Your signature below acknowledges that you have read or heard our notice of privacy practices, which explains in more detail what your rights are and how we can use and share your information.

If you do not sign this form agreeing to our privacy practices, we cannot treat you. In the future, we may change how we use and share your information, and so we may change our notice of privacy practice. If we do not change it, you can get a copy from our office.

If you are concerned about your PHI, you have the right to ask us not to use or share some of it for treatment, payment, or administrative purposes. You will have to tell us what you want in writing. Although we will try to respect your wishes, we are not required to accept these limitations. However, if we do agree, we promise to do as you asked. After you have signed this consent, you have the right to revoke it by writing to our office. We will then stop using or sharing your PHI, but we may have already have used or shared some of it, and we cannot change that.

I understand that a typed version of my name may be accepted as my original signature pursuant to the Georgia Uniform Electronic Transactions Act (O.C.G.A. 10-12-7). To accept the above statement, type "I Understand" in the box below. *

Printed Name of Client or Guardian *

Date *

Signature of Client or Guardian *

In order for this submission to be accepted, you must use the mouse and draw your name in the box above. Clear

If there is a Guardian signing for the Client, please state the relationship of the Guardian to the Client below.