SECTION A: Patient Giving Consent

Name: _______________________________________ Date of Birth: ___________________

Address: ____________________________________________________________________

Telephone: __________________________ Social Security #: _________________________

SECTION B: To the Patient - Please read the following statements carefully

Purpose of Consent
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.

Notice of Privacy Practices
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. The notice has previously been provided to you and is available upon request. We encourage you to read the notice carefully and completely before signing this consent.

We reserve the right to change our privacy practices, as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by download from www.alexdavismd.com or by contacting:

Right to Revoke
You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation, and that we may decline to treat you or continue treating you if you revoke this consent.

Signature

I, ___________________________________, have had full opportunity to read and consider the contents of this consent form and your Notice of Privacy Practices. I understand that by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations.

Signature: _____________________________________ Date: ________________
(Patient or Representative if patient is a minor)

Representative's Name: __________________________________________________

Relationship to Patient: ___________________________________ (If Applicable)

You are entitled to a copy of this consent after you sign it.

Include completed Consent in the patient's chart

Permission to Release Information

I give my permission to release my protected health information to the following person(s):

Name: ___________________________________________________________________

Relationship to patient: ______________________________________________________

Signature: _______________________________________ Date: ___________________

Revocation of Consent

I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations.

I understand that revocation of my consent will not affect any action you took in reliance on my consent before you received this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my consent.

Signature: ____________________________________ Date: _____________________

If this Revocation of Consent is signed by a representative on behalf of the patient, complete the following:

Representative's Name: ________________________________________________________

Relationship to Patient: _________________________________________________________