By signing this I am acknowledging that I have read and understand BodyK’s Notice of Privacy Practices. I have had full opportunity to read and consider the contents of Privacy Practices. I understand that, by signing this acknowledgement and consent form, I am giving my consent for this office’s use and disclosure of my protected health information to carry out treatment, payment activities and health care options.
A copy of our Notice of Privacy Practices is available online on our website. 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. These changes may apply to any of your protected health information that we maintain. You may obtain another copy of our Notice of Privacy Practices, including revisions, at any time by contacting our Privacy Officer at BodyKnows@bodyk.net. This consent expires after one year.