I have received (or have been offered) a copy of this office’s Notice of Privacy Practices. By signing this form, you are giving this office your consent to use and disclose health information about you for treatment, payment, and health care operation purposes.

Additionally, by signing this form, I give my authorization to disclose health information to the parties listed below to assist with treatment and/or payment for services and allow the release of records or x-rays for the named patient.