PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

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I hereby give my consent for Refreva Mental Health Clinic and/or its affiliates to use and disclose protected health information (PHI) about me to carry out treatment, payment, and health care operations (TPO).

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The Notice of Privacy Practices provided by Refreva describes such uses and disclosures more completely. I have the right to review the Notice of Privacy Practices prior to signing this consent. Refreva reserves the right to revise its Notice of Privacy Practices at any time. A revised copy may be obtained by forwarding a written request to Refreva.

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With this consent, Refreva may contact me via phone, mail, or email regarding appointment reminders, billing, and matters related to my clinical care. I understand that such communications will be conducted in a confidential manner.

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I have the right to request restrictions on how my PHI is used or disclosed. Refreva is not required to agree to these restrictions, but if it does, it is bound by that agreement.

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By signing this form, I consent to Refreva’s use and disclosure of my PHI to carry out TPO. I may revoke this consent in writing at any time, except to the extent that the clinic has already relied on it. If I do not sign this consent, or later revoke it, Refreva may decline to provide treatment.

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Acknowledgment of Receipt of Privacy Practices

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I acknowledge that I will be provided a copy of the Notice of Privacy Practices for Refreva, upon request.

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Patient Rights and Responsibilities

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Our clinic is committed to providing high-quality, respectful care. Below are your rights and responsibilities:

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You have the right to:
- A personal clinician providing ongoing care.
- Respectful treatment, free of discrimination.
- Second medical opinions.
- Clear explanations of conditions and treatment.
- Access to your records.
- Confidential handling of your information.
- Informed consent and refusal rights.
- Humane and individualized treatment.
- Pain assessment and management.
- Refuse participation in research.
- Review and explanation of bills.
- File complaints and change clinicians.

You are responsible for:
- Providing accurate health and contact information.
- Bringing insurance and medication details.
- Following treatment plans.
- Keeping appointments and paying fees.
- Respectful conduct toward staff and others.

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