Patient Disclosure and Consent Form

Please Read Carefully Before Completing and Submitting This Form.

By completing and submitting this form, you acknowledge and agree to the terms and conditions outlined below, including the collection and use of your personal health information in accordance with applicable laws and regulations.

Patient Rights and Responsibilities:

• By submitting this form, you consent to the collection of your personal and medical information by Medical Essentials LLC. This information will be used to facilitate your healthcare services and appointments.

• You have the right to refuse to provide certain personal information, but please note that doing so may limit our ability to provide you with healthcare services.

• Your healthcare provider will discuss any necessary treatments or interventions with you and will ensure that you understand the potential risks and benefits of the treatment options available.

Confidentiality and Privacy:

• All information provided will be kept confidential in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and any other applicable state and federal laws governing the protection of health information.

• We may share your health information with other healthcare professionals involved in your care, as necessary, to ensure you receive comprehensive treatment.