SPENCE COUNSELING CENTER, P.C.

 

Consent to Treatment, Use, and Disclose Your Health Information

 

This form is an agreement between you, ______________________________ and me/us Spence Counseling Center, P.C.  When we use the word “you” below, it will mean your child, relative, or other person if you have written his or her name here ___________________________.

 

When we examine, diagnosis, treat, or refer you, we will be collecting what the law calls Protected Health Information (PHI) about you.  We need to use this information to decide what treatment is best for you and to provide treatment to you.  We may also share this information with others who provide treatment to you or need it to arrange payment for your treatment or for other business or government functions.

 

By signing this form, you are agreeing to let us use this information here and send to others.  The Notice of Privacy Practices explains in more detail your rights and how we can use and share your information.  Please read this before you sign this Consent form.

 

If you do not sign this Consent Form agreeing to it and what is in our Notice of Privacy Practices,

we can not treat you.

 

We have the right to change or Consent and Notice of Privacy Practices and we will notify if we change them.  You are always welcome to a copy of our Notice and our Policies and Procedures.  If you are concerned about some of your information, you have the right to ask us.  You will have to tell us what you want in writing.  Although we will try to respect your wishes, we are not required to agree to these limitations.  However, if we do agree, we promise to comply with your written request.

 

After you have signed this consent, you have the right to revoke it (by writing a letter telling us you no longer consent) and we will comply with your wishes about using or sharing your information from that time on, but we may already have used or shared some of your information and can not change that.

 

____________________________________________        ________________________

Signature of client or his or her personal representative    Date

____________________________________________        ________________________

Printed name of client or personal representative             Relationship to the client

_______________________________________________________________________ 

Description of personal representative’s authority

 

Receipt of Notice of Privacy Practices Written Acknowledgement

 

I, ______________________, have received a copy of the Spence Counseling Center’s Notice of Privacy Practices.

           Client Name

 

_______________________________                                              ________________________

Signature of Client                                                                     Date

 

IF CLIENT IS A MINOR:

 

I, ______________________, have received a copy of the Spence Counseling Center’s Notice of Privacy Practices

           Parent/Guardian Name

parent/guardian of _____________________________.

                                                Client Name

 

_______________________________                                              ________________________

Signature of Client                                                                     Date