I, [patient name], give this practice/clinic my consent to use or disclose my protected health information to carry out my treatment to Doug Cournish, D.M.D.
I have been informed that I may review the practice/clinic's Notice of Privacy Practices (for a more complete description of uses and disclosures) before signing this consent.
I understand that this practice/clinic has the right to change their privacy practices and that I may obtain any revised notices at the practice/clinic.
I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice/clinic is not required to agree to the request. If the practice/clinic agrees to my requested restriction, they must follow the restriction(s).
I also understand that I may revoke this consent at any time, by making a request in writing, except for information already used or disclosed.