ࡱ> _ V !"#$%&'()*+-./0123456789:;<=>?ABCDEFGHIJKLMOPQRSTUXYZ[\]^`aRoot Entry( Jr0(sMatOST [(s(sMMMN0 ND  FMicrosoft Office Word Document MSWordDocWord.Document.89quST   6=/d ,t6HTMatadorObject2 F[(s[(sOle 1Table} CompObjq@@@ NormalCJ_HaJmH sH tH DAD Default Paragraph FontRiR  Table Normal4 l4a (k(No List& z&ope2GH  (0*f0*f0*/0*0*0*0*0*0*^0*0*^0*G0* 0*G0* 0*G0*G0*v:0*v:0*v:0*v:0*v:0*v:0*v:0*0*v:0*0*0*0*0*0*0*ope2GH  (@0@0@0@0@0@0@0@0@0@0@0@ 0@ 0@ 0@ 0@ 0@ 0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0& & & 8@(  NB  S DoB S  ?&LB*`teF }7 $8B yLȤ]Ocfh88^8`OJQJo(hHh^`OJQJ^Jo(hHoh  ^ `OJQJo(hHh  ^ `OJQJo(hHhxx^x`OJQJ^Jo(hHohHH^H`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHhhh^h`OJQJ^Jo(hHoh88^8`OJQJo(hHh^`OJQJo(hHh  ^ `OJQJ^Jo(hHoh  ^ `OJQJo(hHhxx^x`OJQJo(hHhHH^H`OJQJ^Jo(hHoh^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHopp^p`OJQJo(hH@ @ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoPP^P`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hH^`OJQJo(hH  ^ `OJQJ^Jo(hHo  ^ `OJQJo(hHxx^x`OJQJo(hHHH^H`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hHeOc}7 yL$8B                                               R:\hZB.*:lwHt2S#Y$^[O!=@&@UnknownGz Times New Roman5Symbol3& z Arial?& Arial Black?5 z Courier New;Wingdings"hff77!r4d""3QHP)?!=2Patient Consent FormPatrick SullivanPatrick Sullivan      OlePres000 A(OlePres001,'WordDocument @4SummaryInformation( N/ )winspoolCanon i550 (Copy 1)Ne02: L%T'    *."System*yoH9@ -@"Arial Black- )2 0Patient Consent FormTN4'NN4'[MNGNM4'NN4u- @ !l- 2 0 b 2 %0 c@"Arial Black- 2 0 9@"Arial-2 KW0Our Notice of Privacy Practices provides information about how we may use and disclose N8!H8287C!1821C!822828!8188277!T878788888GG8T818288878228272 vK`0protected health information about you. The Notice contains a Patient Rights section describing 8!88288888878!S8888878188=88G8282788818C877H782282878822!887V2 K20your rights under the law. You have the right to r188!!7828888!787GB88881888!788!V2 20eview our Notice before signing this Consent. The 818G88!H828878!82788782H88278>782 \K[0terms of our Notice may changes. If we change our Notice, you may obtain a revised copy by b8!T2778!H828T712888782G828787888!H728188T8188888!81288188181,2 K0contacting our office.288818788!728 2 0 5 2 BK0 62 K[0You have the right to request that we restrict how protected health information about you ibB88881878!788 8788288G8!82!288G8!88278788878!S87887881882 0s used 282872 (Kc0or disclosed for treatment, payment or healthcare operations. We are not required to agree to this s8!82282878!!78S88881T788!888728!8878!8782b78!887!878!88887!87882a2 K90restriction, but if we do, we shall honor that agreement.!82!28878G887G82888878!7877!88T87 2  0 5 2 K0 62 K[0By signing this form, you consent to our use and disclosure of protected health informationbC127887828!S188278287888!828888822828!878!87288888878!T7872 0 about 88782 Ka0you for treatment, payment and healthcare operations. You have the right to revoke this Consent, s1888!!88T78881T87788888828!8788!8782B88881878!788!8182882H882782 gK_0in writing, signed by you. However, such a revocation shall not affect any disclosures we have 8G!972788881198H8G818!28288!818287828888782881822828!82G88718a2 K90already made in reliance on your prior Consent. The Pract8!8881T7887!8872887188!8!8!H88278>78C!82J2 U *0ice provides this form to comply with the 188!81882828!T818S81G888q2 MKD0Health Insurance Portability and Accountability Act of 1996 (HIPAA).H888828!7828B8!781888C22788881C277888!HBCC! 2 M 0 6@"Arial- 2 K0 $-72 K0The patient understands that:>7878877888!2878278 2 a0 5- 2 a K0 $@Symbol- 2 0*@"Arial- 2 0 l2 w[0Protected health information may be disclosed or used for treatment, payment or healthcare a=33-33333222M233M3-323..3.3333.33232M2333-L3323333-320'2 5 w 0operations.333333. 2 5 >0 00'- 2 0*- 2 0 l2 w 0The Practi932=3-2 X0ce has a Notice of Privacy Practices and that the patient has the opportunity to review .333-3B2.32=-3.-=3..3.3233233323333.32333333-23-3A0'2  w 0this Notice.3.B3.2 2  =0 00'- 2 } 0*- 2 } 0 ly2 } wI0The Practice reserves the right to change the Notice of Privacy Policies.932=3-.32.3-3.23432.3324232B3.32<-3.-=3/3. 2 } 0 10'- 2 0*- 2 0 l2 wQ0The patient has the right to restrict the uses of their information but the Practr932333333-324333..323.3-23223M3323332=2.+2 0ice does not have to ..3333-3333-320'52 V w0agree to those restrictions.3333333.33-.32. 2 V 0 00'- 2 0*- 2 0 l2 wf0The patient may revoke this Consent in writing at any time and all future disclosures will then cease.9323333M3-3-3/23.B33.332A34233-M333232323..3.33.A333.33.2 2 F0 00'- 2 5 0*- 2 5 0 lw2 5 wH0The Practice may condition treatment upon the execution of this Consent.932=3-.3M3-.3333333M333333323-3.33323.B33.33 2 5  0 00'@"Arial- 2 0 -0' 2 0 -0' 2 W0 -0' 2 0 -0' 2 0 -0' 2 v0 -0' 2 0 -0'-,2 EK0This Consent was signe>82H78278G8227882 Eq0d by881-n2 E.B0: __________________________________________________________/../../.././.../../.././../../..//.../../.././../../..//.. 2 Eg0 .0' 2 K0 -0'-2 KY0Relationship to Patient (if other than patient): ____________________________________H88882887C788!888!8787887!788787887887878788788788787887887788 2 d0 50' 2 K0 60'/2 K0Date: _______________H88788788787887888 2 0 50' 2 qK0 60'p2 KC0Witness: _______________________________________________________sa882187887887788788788787887887788788788787887887788788788782 - 0__________7887887788 2 Y0 50' 2 VK0 60'12 K0Date: _______________nH88787887887878878 2 0 50'- - %0- - '-NANI L%TL%T'    *."System*yo<9@ -@"Arial Black- )2 0Patient Consent FormTN4'NN4'[MNGNM4'NN4u- @ !l- 2 0 b 2 %0 c@"Arial Black- 2 0 9@"Arial-2 KW0Our Notice of Privacy Practices provides information about how we may use and disclose N8!H8287C!1821C!822828!8188277!T878788888GG8T818288878228272 vK`0protected health information about you. The Notice contains a Patient Rights section describing 8!88288888878!S8888878188=88G8282788818C877H782282878822!887V2 K20your rights under the law. You have the right to r188!!7828888!787GB88881888!788!V2 20eview our Notice before signing this Consent. The 818G88!H828878!82788782H88278>782 \K[0terms of our Notice may changes. If we change our Notice, you may obtain a revised copy by b8!T2778!H828T712888782G828787888!H728188T8188888!81288188181,2 K0contacting our office.288818788!728 2 0 5 2 BK0 62 K[0You have the right to request that we restrict how protected health information about you ibB88881878!788 8788288G8!82!288G8!88278788878!S87887881882 0s used 282872 (Kc0or disclosed for treatment, payment or healthcare operations. We are not required to agree to this s8!82282878!!78S88881T788!888728!8878!8782b78!887!878!88887!87882a2 K90restriction, but if we do, we shall honor that agreement.!82!28878G887G82888878!7877!88T87 2  0 5 2 K0 62 K[0By signing this form, you consent to our use and disclosure of protected health informationbC127887828!S188278287888!828888822828!878!87288888878!T7872 0 about 88782 Ka0you for treatment, payment and healthcare operations. You have the right to revoke this Consent, s1888!!88T78881T87788888828!8788!8782B88881878!788!8182882H882782 gK_0in writing, signed by you. However, such a revocation shall not affect any disclosures we have 8G!972788881198H8G818!28288!818287828888782881822828!82G88718a2 K90already made in reliance on your prior Consent. The Pract8!8881T7887!8872887188!8!8!H88278>78C!82J2 U *0ice provides this form to comply with the 188!81882828!T818S81G888q2 MKD0Health Insurance Portability and Accountability Act of 1996 (HIPAA).H888828!7828B8!781888C22788881C277888!HBCC! 2 M 0 6@"Arial- 2 K0 $-72 K0The patient understands that:>7878877888!2878278 2 a0 5- 2 a K0 $@Symbol- 2 0*@"Arial- 2 0 l2 w[0Protected health information may be disclosed or used for treatment, payment or healthcare a=33-33333222M233M3-323..3.3333.33232M2333-L3323333-320'2 5 w 0operations.333333. 2 5 >0 00'- 2 0*- 2 0 l2 w 0The Practi932=3-2 X0ce has a Notice of Privacy Practices and that the patient has the opportunity to review .333-3B2.32=-3.-=3..3.3233233323333.32333333-23-3A0'2  w 0this Notice.3.B3.2 2  =0 00'- 2 } 0*- 2 } 0 ly2 } wI0The Practice reserves the right to change the Notice of Privacy Policies.932=3-.32.3-3.23432.3324232B3.32<-3.-=3/3. 2 } 0 10'- 2 0*- 2 0 l2 wQ0The patient has the right to restrict the uses of their information but the Practr932333333-324333..323.3-23223M3323332=2.+2 0ice does not have to ..3333-3333-320'52 V w0agree to those restrictions.3333333.33-.32. 2 V 0 00'- 2 0*- 2 0 l2 wf0The patient may revoke this Consent in writing at any time and all future disclosures will then cease.9323333M3-3-3/23.B33.332A34233-M333232323..3.33.A333.33.2 2 F0 00'- 2 5 0*- 2 5 0 lw2 5 wH0The Practice may condition treatment upon the execution of this Consent.932=3-.3M3-.3333333M333333323-3.33323.B33.33 2 5  0 00'@"Arial- 2 0 -0' 2 0 -0' 2 W0 -0' 2 0 -0' 2 0 -0' 2 v0 -0' 2 0 -0'-,2 EK0This Consent was signe>82H78278G8227882 Eq0d by881-n2 E.B0: __________________________________________________________/../../.././.../../.././../../..//.../../.././../../..//.. 2 Eg0 .0' 2 K0 -0'-2 KY0Relationship to Patient (if other than patient): ____________________________________H88882887C788!888!8787887!788787887887878788788788787887887788 2 d0 50' 2 K0 60'/2 K0Date: _______________H88788788787887888 2 0 50' 2 qK0 60'p2 KC0Witness: _______________________________________________________sa882187887887788788788787887887788788788787887887788788788782 - 0__________7887887788 2 Y0 50' 2 VK0 60'12 K0Date: _______________nH88787887887878878 2 0 50'- - %0- - '-q` &bjbjqPqP 4::&    " rB B B B B prrrrrr$ch s " B B 1 B B p p h$B 6 Ds Pp0`] ] $] $L   $   Patient Consent Form Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may changes. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or healthcare operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and healthcare operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The patient understands that: Protected health information may be disclosed or used for treatment, payment or healthcare operations. The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice. The Practice reserves the right to change the Notice of Privacy Policies. The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions. The patient may revoke this Consent in writing at any time and all future disclosures will then cease. The Practice may condition treatment upon the execution of this Consent.  This Consent was signed by: __________________________________________________________ Relationship to Patient (if other than patient): ____________________________________ Date: _______________ Witness: _________________________________________________________________ Date: _______________ o p H%&Ƕ؃h\hhZB.OJQJ^J.jhZB.CJOJQJU^JaJmHnHuhZB.CJOJQJ^JaJ hhZB.CJOJQJ^JaJ h$^hZB.CJOJQJ^JaJhZB.OJQJ^Jh$^hZB.>*CJOJQJaJhZB.>*CJOJQJaJ o p e 2  :^`:gdZB. & F gdZB.gdZB.$a$gdZB.&GH  &  8^`8gdZB. 21h:pwHth. =!"#$% Oh+'0 $ D P \ ht|Patient Consent FormPatrick SullivanNormalPatrick Sullivan2Microsoft Office Word@@@> s@> s7DocumentSummaryInformation8WCompObjU՜.+,0 hp|   " Patient Consent Form Title   {w{  qq !  MOMO 0*.0*. Times New Roman =/=/d ( JrMicrosoft Works MSWorksWPDoc9q