Patient Giving Consent:
Please read the following statements carefully:
By Signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.(Without signature, we may decline to treat you.)
You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations; of the uses and disclosures we may make of your protected health information; and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting: Dr. Danielle Ross, 25 Indian Rock Rd., Suite 14, Windham, NH 03087 (603)216-1178.
I am giving my consent to disclose my patient care record and protected health information to the following person(s).
Including those involved in my care or payment for that care:
I had full opportunity to read and consider the contents of this Consent form and Privacy Practices. I understand that, by signing this Consent form, I am giving consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations.
If this Consent is signed by a personal representative on behalf of the patient, complete the following: