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Consents

By signing this form, I understand and consent to the following:

  • Our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this 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 the 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 the execution of this consent.
  • Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

Permissions: I give permissions for the following:

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