Consent to use and disclose your health information

This form is an agreement between you, ___________________________________ and

A. Elaine Flannagan.

When I examine, test, diagnose, treat, or refer you I will be collecting what the law calls Protected Healthcare Information (PHI) about you. I need to use this information here to decide on what treatment is best for you and to provide any treatment to you.

I may also share this information with others who provide treatment to you or need it to arrange payment for your treatment or for other business or government functions.

By signing this form you are agreeing to let me use your information and send it to others. The Notice of Privacy Practices explains in more detail your rights and how I can use and share your information. Please read this before you sign this consent form. If you do not sign this consent form agreeing to what is in this Notice of Privacy Practices, I cannot treat you.

In the future I may change how I use and share your information and so may change this Notice of Privacy Practices. If I do change it, you can get a copy from me.

If you are concerned about some of your information, you have the right to ask me to not use or share some of your information for treatment, payment, or administrative purposes. You will have to tell me what you want in writing.

Although I will try to respect your wishes, I am not required to agree to these limitations. However, if I do agree, I promise to do as you have asked.

After you have signed this consent, you have the right to revoke it by writing a letter telling me you no longer consent. I will comply with your wishes about using or sharing your information from that time on.

However, I may already have used or shared some of your information and that I cannot change.