HIPAA Form

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. A copy of our Notice
accompanies this Consent. We encourage you to read it 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 contacting us at the abovementioned address.
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 this office. 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 to continue treating you if you revoke this Consent.

Child's Name

Your Name

Relationship to Patient
Select One Father Mother Guardian

Date