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 the 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 y`ou 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 our use and disclosure 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.

Palm Glades Rural Health Associates, Inc. provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 

The Patient understnds that:

1Protected health information may be disclosed or used for treatment, payment or health care operations

2Palm Glade Rural Health Associates has a Notice of Privacy Practices and that the  patient has the opportunity to review this Notice 

3Palm Glade Rural Health Associates reserves the right to change the Notice of Privacy Policies

4The patient has the right to restrict the uses of their information but Palm Glade Rural Health Associates does not have to agree to those restrictions 

5The patient may revoke this Consent in writing at any time and all future Disclosures will then cease

6Glade Rural Health Associates may condition treatment upon the execution of this Consent