Patient Information Form - Green Valley Ranch Medical Clinic & Urgent Care (Page 4 of 6) in pdf

Patient Information Form - Green Valley Ranch Medical Clinic & Urgent Care Page 4

Green Valley Ranch Medical Clinic & Urgent Care

Consent to Use and Disclosure of Health Information

By signing this form, you are granting consent to Green Valley Ranch Medical Clinic/Urgent Care

to use and disclose your protected health information for the purpose of treatment, payment

and healthcare operations. Our Notice of Health Information Privacy Practices provides more

detailed information about how we may use and disclose this protected health information.

You have a legal right to review our Notice of Health Information Privacy Practices before you

sign this consent, and we encourage you to read it in full.

Our notice of Health Information Privacy Practices is subject to change. If we change our notice,

you may obtain a copy of the revised notice by contacting us at (303) 344-8700, or by

requesting a copy at the front desk. You have the right to request that we restrict how we use

and disclose your protected health information for the purpose of treatment, payment or

healthcare operations. We are not required by law to grant your request. However, if we do

decide to grant your request, we are bound by our agreement.

You have the right to revoke this consent in writing except to the extent we already have used

or disclosed your protected health information in reliance with your consent.

______________________________

_________________

Patient/Legal Guardian

Date

Green Valley Ranch Medical Clinic & Urgent Care

4809 Argonne St. Suite # 100

Denver, CO 80249

Patient Information Form - Green Valley Ranch Medical Clinic & Urgent Care Page 4