By clicking the I AGREE Button. I, The Patient/Parent/Legal Guardian of child, understand that as part of my healthcare, “Carrousel Therapy Center,” originates and maintains paper and/or electronic records, describing “my” (the term “my” refers to Patient/Parent/Legal Guardian of child) health history, symptoms, examinations and test results, diagnoses, treatment, and any plans for future care of 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 contributes to my care, 

-A source of information for applying my diagnosis and surgical information to my bill, 

-A means by which a third-party payer can verify that services billed were actually provided,

-A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals. 

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. 

I understand that I have the following rights and privileges: 

-The right to review the notice prior to signing this consent, 

-The right to object to the use of my health information for directory purposes,

-The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations.

I understand that “Carrousel Therapy Center,” is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations. I further understand that “Carrousel Therapy Center,” reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should “Carrousel Therapy Center,” change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S. mail or if I agree e-mail).