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By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations. You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before singing this consent.

We reserve the right to change our Notice of Privacy Practices before you decide whether to sign this Consent. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting one of our receptionists. Please call 574-273-8393.

Right to Revoke: You will have the right to revoke this Consent at any time by giving written notice of your revocation submitted to our office. Please understand that revocation of this consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you revoke consent I have had full opportunity to read and consider the contents of the Consent form and the Notice of Privacy Practices.