Client’s Name: _________________________________
                                          Please Print

I hereby acknowledge that:

• I have been provided a copy of the Notice of Privacy Practices prior to consenting to the use and disclosure of my Protected Health Information for treatment, payment, and operations;
• I have had the opportunity to ask any questions regarding my rights relating to the use and disclosure of my Protected Health Information; and
• I have been told that I may request restrictions on the use and disclosure of my Protected Health Information.

_____________________________________              ________________
Client Signature or                                                            Date
(If client is under 18, parent, guardian or legal representative’s signature)

_____________________________________
Print Name

Note: If you are signing as the parent, guardian, or legally authorized representative of the client, please indicate your relationship to the client here (this should demonstrate your authority to consent to health care for the client): ____________________________

US/CR134/ Revised 4-03