PATIENT ACKNOWLEDGEMENT OF THE NOTICE OF PRIVACY PRACTICES & CONSENT FOR USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION

I acknowledge that I have either received a copy of this office’s NOTICE OF PRIVACY PRACTICES or that this office’s NOTICE OF PRIVACY PRACTICES was made available to receive.

I consent to the use and disclosure of my personal health information by your office for Health Care as outlined in the NOTICE OF PRIVACY PRACTICES.

I consent to any examination, and/or care to be rendered to me. I give permission to provide medical treatment and services for myself that are deemed necessary including diagnostic and laboratory testing.

If you present any insurance information for laboratory test/blood work, the patient will be fully responsible for any bills received by requesting laboratory.