Use and Disclosure of Your Protected Health Information
    Your protected health information will be used by Creative Prosthetics & Orthotics, LLC or disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice.

    Notice of Privacy Practices
    You should review the Notice of Privacy Practices for a more complete description of how your Protected Health Information (PHI) may be used or disclosed. You may review the notice prior to signing this consent.

    Requesting a Restriction on the Use of Disclosure of Your Information
    You may request a restriction on the use or disclosure of your PHI. Creative Prosthetics & Orthotics, LLC may or may not agree to restrict the use or disclosure of your PHI. If Creative Prosthetics & Orthotics, LLC agrees to your request, the restriction will be binding on the practice. Use or disclosure of PHI in violation of an agreed upon restriction will be a violation of the federal privacy standards.

    Revocation of Consent
    You may revoke this consent to the use and disclosure of your PHI. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation on consent is received will not be affected.

    Reservation of Right to Change Privacy Practices
    Creative Prosthetics & Orthotics, LLC reserves the right to modify the privacy practices outlined in this notice.

    I have reviewed this consent form and give my permission to Creative Prosthetics & Orthotics, LLC to use and disclose my health information in accordance with it. I have been offered and/or given a copy of this form.

    First Name:

    Last Name:

    Legal Guardian printed name:

    Relationship to Patient:

    Person(s) with whom Creative Prosthetics & Orthotics, LLC may discuss financial or PHI information if I am not available:

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