Consent for Use and Disclosure of Health Information

  • Section A: Patient Giving Consent

  • Section B: To the Patient – Please Read the Following Statements Carefully

  • Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations (TPO).

    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 your 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 your protected health information that we maintain.

    With my permission the office of EBS Therapy of New York may call my home or other designated location and leave messages on voice mail that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any call pertaining to my clinical care.

    With my permission the office of EBS Therapy of New York may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminders and patient invoices and statements.

    With my permission the office of EBS Therapy of New York may e-mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder and patient invoices and statements.

    I have the right to request that EBS Therapy of New York restrict how it uses or discloses my protected health information to carry out TPO. However, the practice is not required to agree to my restrictions, but if it does, it is bound by this agreement.

    You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

    Contact Officer: Jeri Blum, M.S., CCC-SLP
    Telephone: 718-238-0377
    E-mail: jeri.blum@ebsciny.com

    Right to Revoke: You will have the right to revoke this Consent at any time by giving written notice of your revocation submitted to EBS Therapy of New York. Please understand that 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 to continue treating you if you revoke this Consent.


  • I have received a copy of this office's Notice of Privacy Practices. (You may obtain a copy in our office.) If this Consent is signed by a personal representative on behalf of the patient, complete the following:



  • REVOCATION OF CONSENT

    I revoke my Consent for your use and disclosure of my protected health information for treatments, payment activities, and healthcare operations.

    I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my Consent.



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