Patient Consent for Use and Disclosure of Protected Health Information

In signing this form, you consent to the use and disclosure of your protected health information by Cary Surgical Specialists, PC, our staff and our business associates strictly for the purpose of treatment, payment and health care operations.

You acknowledge you have had an opportunity to review our Notice of Privacy Practices prior to signing this consent. We encourage you to review our Notice of Privacy Practices carefully. It provides more detail on how we may use and disclose your information. The Notice of Privacy Practices may change. A current copy may be requested when you are being seen as a patient by contacting our manager at (919) 859-9191 or by visiting our website at http://www.carysurgical.com/index.html

You may request that we restrict how we use and disclose your protected health information for the purposes mentioned above. If you would like to request a restriction, please do so in writing. However, we reserve the right to deny your request. If we grant your request, we are bound by the terms of the agreement.

You may also revoke this consent in writing; however, information on any treatment and services provided using this or prior consents may still be used or disclosed for purposes of treatment, payment, or health care operations. Refer to the Notice of Privacy Practices for further information.

By signing this form, I grant my consent for the practice to use and disclose my protected health information for the purposes of treatment, payment and health care operations

Signature of Patient ________________________________________ Date _________

Signature of Parent if Minor __________________________________Date _________

Power of Attorney Signature _________________________________ Date _________

Name of other that may have your records ______________________ Date _________

Relationship to Patient _________________________

For Practice Use Only

Failure to obtain consent:

Indirect Treatment Relationship

Substantial Communication Barrier

Emergency Treatment

Refusal to Sign

Other

Description: ___________________________________________________________________________

Practice Signature______________________________________________________ Date ____________

Witness______________________________________________________________ Date ____________