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Please print this form, sign it, date it and bring it to your first appointment. Thank You. |
| 40th Street Medical, PC |
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275 Madison Avenue
Suite 1611
New York, NY 10016
212-986-3888
Consent Agreement
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I, ___________________________________ understand that as part of my healthcare, this practice originates and maintains health records describing my health history, symptoms, examinations and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:
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- A basis for planning my care and treatment
- A means of communication among the many health professionals who contribute to my care
- A source of information for applying my diagnosis information to my bill
- A means by which a third-party payer can verify that services hilled were actually provided
- A tool for routine healthcare operations such as assessing the quality and reviewing the competence of health care professionals
I understand and have been provided with a notice of Information practices that provides a more complete description of the information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand the organization reserves the right to change their notice and practices prior to implementation will mail a copy of any revised notice to the address above that I've provided. I understand that I have the right to object to the use of lily health information for directory purposes. I understand that I have the right to request restrictions as to how my health information my be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.
I wish to have the following restrictions to the use or discloser of my health information.
I fully understand and accept the terms of this consent.
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