HIPAA

SECTION B: TO THE PATIENT ‐ PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY Purpose of Consent: By signing this form you will consent to our use and disclosure of your protected health informaƟon to carry out treatment, payment acƟviƟes and healthcare operaƟons. NoƟce of Privacy PracƟces: You have the right to read our NoƟce of Privacy PracƟces before you decide whether to sign this Consent. Our NoƟce provides a descripƟon of our treatment, payment acƟviƟes and healthcare operaƟons, of the use and disclosures we may make of your protected health informaƟon and of other important maƩers about your protected informaƟon. A copy of our NoƟce accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy pracƟces as described in our NoƟce of Privacy PracƟces. If we change our privacy pracƟces, we will issue a revised NoƟce of Privacy PracƟces which will contain the changes. Those changes may apply to any of your protected health informaƟon that we maintain. You may obtain a copy of our NoƟce of Privacy PracƟces, including any revisions of our NoƟce at any Ɵme by contacƟng: Contact Person: Leslie Coolidge Telephone #: (202) 244‐6111 Email: offi[email protected] Address: 5028 Wisconsin Ave, NW Suite 200 Washington, DC 20016 Right to Revoke: You will have the right to revoke this Consent at any Ɵme by giving us wriƩen noƟce of our revocaƟon submiƩed to the Contact Person listed above. Please understand that revocaƟon for this Consent will not affect any acƟon we take in reliance on this Consent before we received your revocaƟon, and that we may decline to you or to conƟnue treaƟng you if you revoke this Consent.