This consent is for Davis Mobility Co., including all sales associates, delivery technicians, office support staff, management and owners. 

The purpose of this consent form is to inform you, the patient, how your personal health information is used and/or disclosed by this provider or organization. We want you to be fully aware of what we do with your information so that you can provide us with your consent in order for us to treat your health care needs, receive payment for services rendered, and allow administrative and other types of health care operations to happen, which are part of normal business activities of this provider or organization.  

Your consent

I understand that as part of my health care, this organization originates and maintains health records describing my health history, symptoms, test results, diagnoses, treatment, and plans for future care or treatment.  I understand that this information serves as:
 

• A basis for planning my care and treatment.
• A means of communication among the many health professionals who contribute to my care.
• A source of information for applying my diagnosis/es and other health information to my bill(s).
• A means by which my health plan or health insurance company can verify that services billed were actually provided.
• A tool for routine health care operations in this organization, such as ensuring that we have quality processes and programs in place and making sure that the professionals who provide your care are competent to do so. 

I understand that:
 

• I have been provided with a Notice of Privacy Practices that provides specific examples and descriptions of how my personal health information is used and disclosed by Davis Mobility Co;
• I have the right to review the Notice of Privacy Practices prior to signing this consent;
• Davis Mobility Co. can change its Notice of Privacy Practices but must notify me of those changes before they are put into practice and will mail me a copy of the new Notice to the address that I have provided;  
• I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations and that Davis Mobility Co. is not required to agree to those restrictions; 
• Any restrictions to which Davis Mobility Co. agrees to will be respected.
• I may revoke this consent in writing at any time. Further, I am aware that Davis Mobility can proceed with uses and disclosures that pertain to treatment, payment, or healthcare issues that took place before the consent was revoked.

I request the following restrictions to the use or disclosure of my health information:

I request the following restrictions to the use or disclosure of my health information:

___________________________________

For provider use only:
Restriction is
__ Accepted 
__ Denied

Reason denied: 
Patient is notified? 
__ Yes
__ No

___________________________________

Please provide your signature below to indicate that you have read the above consent and have reviewed the Notice of Privacy Practices. 

_____________________________________
Signature of Patient or Legal Representative

_____________________________________
Witness

________________
Date

________________
Effective Date