Patient Consent and Acknowledgement of Receipt of Privacy Notice

As part of the provision of healthcare services, Brookside Women’s Medical Clinic, PA creates and maintains health records and other information describing among other things: your health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. You consent to the use and disclosure of your protected health information for the purposes of treatment, payment and health care operations. You have the right to revoke this consent, in writing, except where disclosures have already been made based on your prior consent. This consent is given freely with the understanding that:

Any and all records, whether written or oral or in electronic format, are confidential and cannot be disclosed for reasons outside of treatment, payment, or health care operations without your prior written authorization, except as otherwise provided by law.

A photocopy or fax of this consent is as valid as this original.

You have the right to request that the use of your Protected Health Information, which is used or disclosed for the purposes of treatment, payment, or health care operations, be restricted. Both you and the Practice must agree to any restriction in writing that you request on the use and disclosure of your Protected Health Information and agree to terminate any restrictions in writing on the use and disclosure of your Protected Health Information which had been previously agreed upon.

Thank you so much for all your help. Everyone has been so friendly, supportive, and compassionate. I?m so thankful for this facility. I don?t know what I would have done without you.
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