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I acknowledge and agree as follows.

  1. The Practice’s Privacy Notice has been provided to me prior to my signing this Consent. The Privacy Notice includes a complete description of the uses and/or disclosures of my Protected Health Information (“PHI”) necessary for the Practice.
  2. The Practice reserves the right to change its Privacy Practices that are described in its Privacy Notice, in accordance with applicable law.
  3. The Practice may use and/or disclose my PHI (which includes information about my health or condition and the treatment provided to me) in order for the Practice to treat me and obtain payment for that treatment, and as necessary for the Practice to conduct its specific health care options.
  4. I understand that I have a right to request that the Practice restrict how my PHI is used and/or disclosed to carry out treatment, payment, and/or health care operations. However, the Practice agrees to a requested restriction, then the restriction is binding on the Practice.
  5. I understand that this Consent is valid for seven years. I further understand that I have the right to revoke this Consent, in writing at any time for future transactions, with the understanding that any such revocation shall not apply to the extent that the Practice has already taken action in reliance on this Consent.
  6. I understand that if I revoke this Consent at any time, the Practice has the right to refuse providing me with any treatment.
  7. I understand that if I do not sign this Consent evidencing my consent to the uses and disclosures described to me above and contained in the Privacy Notice, then the Practice will not treat me.