Consent for Purpose of Treatment Payment and Healthcare Operations

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I consent to the use or disclosure of my protected health information by Family Practice Associates for the purpose of diagnosing or providing treatment to me, obtaining payment for my healthcare bills or to conduct healthcare operations of Family Practice Associates.

I have the right to revoke consent, in writing at any time, except to the extent that Family Practice Associates has taken action in reliance on this consent.

My “protected health information” means health information, including my demographics information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a healthcare clearinghouse. This protected health information relates to my past, present, or future physical or mental health or condition and identifies me or there is a reasonable basis to believe the information may identify me.

Electronically Signed
I, the undersigned, acknowledge and agree that by typing my name, clicking “I Accept,” or by other electronic means, I am signing this document electronically.
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