Consent for Use and Disclosure of Health Information

Right to Revoke: You will have the right to revoke thi¢:Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above: Please understand that revocation of this Consent will not affect any action we took In reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you If you revoke this Consent.

I, have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

If this Conserit is signed by a personal representative on behalf of the patient, complete the following:

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.
Include completed Consent in the patient's chart