Consent for Purpose of Treatment,
Payment and Healthcare Operations
I acknowledge that Custom Wellness’ “Notice of Privacy Practices” has been made available to me.
I understand I have a right to review Custom Wellness’ Notice of Privacy Practices prior to signing this document. This Notice describes the types of uses and disclosures of my protected health information that will occur in my program, payment of my bills and in the performance of health care operations at Custom Wellness. This Notice also describes my rights and Custom Wellness’ duties with respect to my protected health information.
Custom Wellness reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.
I understand I have a right to review Custom Wellness’ Notice of Privacy Practices prior to signing this document. This Notice describes the types of uses and disclosures of my protected health information that will occur in my program, payment of my bills and in the performance of health care operations at Custom Wellness. This Notice also describes my rights and Custom Wellness’ duties with respect to my protected health information.
Custom Wellness reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.
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