Health Information Consent Form
Date of Birth
LEARNING SOLUTIONS 2 Main StreetFlorence, MA 01062-3500(413) 584-0265 ∙ Fax (413) 584-2031
CONSENT TO USE AND DISCLOSE YOUR HEALTH INFORMATION
This form is an agreement between you and Learning Solutions. When we use the word “you” below it will mean your child, relative, or other person if you have written his name here.
When we examine, diagnose, treat, or refer you we will be collecting what the law calls Protected Health Information (PHI) about you. We need to use this information here to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others who provide treatment to you or need it to arrange payment for your treatment or for other business or government functions.
By signing this form you are agreeing that you have read and understood our Notice of Privacy Policies and you are agreeing to let us use your information here and send it to others in accordance with our written policies. Please make sure you have read and understood our Privacy Policies above before signing this Consent form.
If you do not sign this consent form agreeing to what is in our Notice of Privacy Policies, we cannot treat you.
In the future, we may change how we use and share your information and so may change our Notice of Privacy Policies. If we do change it, you can get a copy from our website or by calling us at 413-584-0265.
If you are concerned about some of your information, you have the right to ask us not to use or share some of your information for treatment, payment, or administrative purposes. You will have to tell us what you want in writing. Although we will try to respect your wishes, we are not required to agree to these limitations. However, if we do agree, we promise to comply with your wish.
After you have signed this consent, you have the right to revoke it (by writing a letter telling us you no longer consent) and we will comply with your wishes about using or sharing your information from that time on but we may already have used or shared some of your information and cannot change that.
I authorize John Gordon, M.A., CCC-SLP; Rachel Currie-Rubin, Ed.D.; Rachael Goren, Ph.D.; Duncan Laird, MSW, LICSW; Margaret Miller, Ed.D.,; Kevin Tobin, PhD; Cassandra Golding, PhD., David Kieval, PsyD, BCBA; Elaine Whitlock (editor) to release/obtain information to/from the following individuals:
Please fill in the names and phone numbers and/or email address of individuals that Learning Solutions may contact to learn more about this client (e.g., therapists, teachers, family members etc.):
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Health Information Consent Form
Agree & Sign