Terms and Conditions

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 I hereby acknowledge, agree, and authorize all of the following:

a) Accurate Information. I certify that the information provided on this form is

accurate, complete, and up to date to the best of my knowledge.

b) Patient Rights and Responsibilities. I understand that the healthcare facility

maintains a Notice of Privacy Practices, which describes how my protected

health information may be used and disclosed, and how I may access my health

records. I understand that I have the right to review this healthcare facility’s

Notice of Privacy Practices prior to signing this form. 

c) Release of Medical Information. I authorize the release of my health

information to the healthcare facility in accordance with the healthcare facility’s 

Notice of Privacy Practices. This includes, but is not limited to, releasing medical

information to my referring physician, primary care physician, and any 

physician(s) I may be referred to. The healthcare facility shall ensure all health

information remains confidential, as required by HIPAA, and will not release any

of my health information without my consent. 

d) Consent for Treatment. I grant the healthcare facility, including its affiliated

providers, physicians, and other medical personnel, permission to use the health

information provided for the purpose of my medical treatment as necessary.

e) Consent to Communication. I consent to receiving communications from the 

healthcare facility regarding appointment reminders, test results, and other 

necessary healthcare-related information via phone, email, or channels.

f) Acknowledgment. By scheduling, I hereby acknowledge, agree, and 

authorize all the above.