Consent For Review And Release Of Information 

I acknowledge receipt of The Notice of Privacy Practices and was given an opportunity to ask questions

and voice concerns. I understand that the agency may use or disclose protected health information about

me to carry out treatment, payment, or health care operations. The agency may release information to or

receive information from insurance companies, health plan, Medicare, Medicaid, or any other person or

entity that may be responsible for paying or processing for payment any portion of my bill for services.

Any person or entity affiliated with or representing for purposes of administration, billing, or quality and

risk management. Any hospital, nursing home or other health facility to which I may be/ have been

admitted. Any assisted living or personal care facility of which I am a resident. Any physician providing

my care. Family members and other caregivers who are part of my plan of care. Licensing and accrediting

bodies, and other health care providers to initiate treatment.

Consent to Film or Record

I hereby consent for the agency to record or film my care, treatment, and services and allow the

agency to use photographs/recordings for their internal use, for documenting my medical

condition or for insurance providers to document my condition for payment purposes. The

undersigned understands that he/she has the right to rescind consent before the recordings, films

or other images are used.

****Including the state hot-line 1-800-342-0553 & Chap hot-line 1-800-656-9686****