CONSENT FOR USE AND DISCLOSURE OF

PROTECTED HEALTH INFORMATION

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

This Consent For Use and Disclosure of Protected Health Information is given by the undersigned on the date appearing below:

I specifically acknowledge that:

·         Protected Health Information may be used and disclosed to carry out treatment, payment, or healthcare operations;

·         I have been provided the Notice of Privacy Practices, which contains a more complete description of such uses and disclosures, and I understand that I have the right to review the Notice before signing this Consent;

·         That the terms of the Notice of Privacy Practices may change, and that I can obtain a revised notice after such change by contacting CHS at the address below;

Coordinated Health System of Jefferson County

2121 8^th Avenue North, Suite 200

Birmingham, Alabama 35203

·         That I have the right to request CHS to restrict how my Protected Health Information is used or disclosed to carry out treatment, payment, or healthcare operations, that CHS is not required to agree with such request, but that if CHS does agree to the request, it will be bound by that agreement; and

·         That I have the right to revoke this Consent in writing, unless CHS has already used or disclosed information in reliance on it.

This Consent shall remain in force until I notify CHS in writing that it has been withdrawn.

Date                                        Patient Signature                                 Witness Signature

The Coordinated Health System of Jefferson County, Inc.

2121 8^th Avenue North, Suite 200

Birmingham, Alabama 35203

(205) 327-8254

Consent 4