Complete Weight Loss and

Healthcare, LLC


Phone: (205) 733-1440

Fax: (205) 733-1442

Protected Health Information (PHI)

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Consent for Use or Disclosure of Protected Health Information (PHI) for Payment & Treatment


By signing below, you here by give consent for Complete Weight Loss & Healthcare, LLC (the Clinic) to

use or disclose information about you, or another person for whom you give the authority to sign, that

is protected under federal law, for the sole purposes of treatment and payment.  You may refuse to sign

this consent form.  You should read Notice Privacy Practices and payment for PHI, attached, before signing

this consent.  The terms of the Notice may change from time to time, and you may always get a revised

copy of it by asking the Clinic director for a copy.


You also have the right to request that the Clinic restrict how your PHI is used or disclosed in carrying

out treatment and payment.  Please be aware, however, that the Clinic is not required to agree to these

requested restrictions.  Should the Clinic agree to your requested restrictions, the restrictions are

binding.

Information about you is protected under federal law, and you have the right to revoke this consent at

any time.  This revocation will not apply to action(s) the Clinic has already taken in reliance on your

consent.  By signing below, you recognize that the PHI used or disclosed may be subject to re-disclosure

by the recipient and no longer be protected under federal law.


Complete Weight Loss & Healthcare, LLC, may communicate confidential information, including payment,

invoices, and appointment reminders, to me at the following:


(Place a check mark beside all that you are in agreement to)


________ I allow the Clinic to leave a voice message at the following number: _____________________________

________ I allow the Clinic to mail correspondences to me at the address I provided.

________ I allow the Clinic to send text messages.

________ I allow the Clinic to send an e-mail to the e-mail address I provided.


I authorize the following person(s) to communicate on my behalf with the Clinic concerning my care:


Name: ___________________________________    Relation: ______________________________


Name: ___________________________________    Relation: ______________________________


Signature of patient or Legal Guardian: ____________________________________ Date: ____________________                                     Page 4