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• Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under law. You have the right to review our Notice before signing this consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

• You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

• By signing this form, you consent to use and disclose of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).


• The practices of both licensed and non-licensed person in the health care fields are regulated by their respective state regulatory boards.

• You are entitled to receive information about method of care, techniques used, duration of care, if know, and fee structure. You have the right to know the risk, as well as the benefits, of any therapy, procedures performed, medicinal agent, healing supplement, Homeopathy, herb, or other recommendation made by the health practitioner. All invasive procedures require documented informed consent. You are also to be informed of the health care provider's degree, credentials, and license.

• You have the right to seek a second opinion from another health care provider or terminate care at any time. Understand that by law, "No practitioner may guarantee the outcome or cure."

• You should know that in a professional relationship, sexual intimacy is never appropriate and should be reported to your state Medical Grievance Board. • It is important that you understand that the information provided by you during the care is confidential except in certain circumstances of which you should be informed.

CONFIDENTIALITY - Matters regarding your care will be kept confidential except in the following circumstance: you sign a release of information giving permission to release information to a specific individual or agency; child abuse; patient or client is in imminent danger to self or others; subpoena of records. *

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