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 deciding whether to sign this consent. Our notice describes our treatment, payment activities, and healthcare operations, the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our notice accompanies this consent. We encourage you to read it carefully before signing this consent.
We reserve the right to change our privacy practices as described in our notice of privacy practices in accordance with applicable law. 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 or our notice, at any time by contacting the office at (330) 835-1000.
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 office. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before receiving your revocation. We may decline to treat you or continue treating you if you revoke this consent.