Section B:

Please read the following information:

Purpose of Consent: By signing this form you will consent to our use and disclosure of your protected health information to carry treatment, payment activities, and health operations, and to your employer for workers compensation purpose if needed.
Notice of Privacy Practices: 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 our 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 signing this consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. 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 our protected health information that we maintain. You may obtain a copy of our notice of Privacy Practice, including any revisions in our Notice, at any time by contacting our office at:

20601 E. Dixie Highway, Suite 340, Aventura, Fl. 33180 or 825 Arthur Godfrey Road, Suite 100, Miami Beach, FL 33140
Phone#: (786) 923-4000

Right to Revoke: You will have the right to revoke this consent at any time by giving us written notice of revocation submitted to the contact person listed above. Please understand the 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 continue treating you if you revoke this consent.

Sign Here