I understand that the patient’s health information is private and confidential. I understand that with this consent, I give permission for aspects of my/my child’s private healthcare information to be shared with Axon Health Associates, LLC, as is necessary for services to be provided. I understand that Axon Health Associates, LLC may use and disclose the patient’s personal health information to help provide care to the patient, to handle billing and payment, and to take care of other health care operations. In general, there will be no other uses and disclosures of this information unless I permit it. I understand that sometimes the law may require the release of this information without my permission. By law, Axon Health Associates, LLC must report actual or suspected child or elder abuse to the appropriate authorities. In addition, Axon Health Associates, LLC is legally bound to take appropriate action if my child or I threaten anyone with violence, harm, or dangerous actions. I understand that there is a detailed document titled “Notice of Privacy Practices” that contains more information about the policies and practices protecting my privacy. I understand that I have the right to read the “Notice” before signing this acknowledgement. I am aware that a copy of this notice will be given to me upon my request or that it may be found at axonhealth.org. Axon Health Associates, LLC has established procedures which help meet patient obligations. These procedures may include other signature requirements, written acknowledgements, and authorizations; reasonable time frames for requesting information; charges for copies and non-routine information needs, etc. I will assist Axon Health Associates, LLC by following these procedures if I choose to exercise any of my rights described in the “Notice of Privacy Practices”. My signature below indicates that I have been given the chance to review a current copy of the “Notice of Privacy Practices”.
