CONSENT FOR TREATMENT. I hereby consent to the treatment provided by Elm City Center and its employees or designees. I authorize the mental and physical health care services deemed necessary or advisable by my caregivers to address my needs.


I authorize use and disclosure of my personal health information for the purposes of diagnosing or providing treatment to me, obtaining payment for my care, or for the purposes of conducing the healthcare operations of Elm City Center. I authorize Elm City Center to release any information required in the process of applications for financial coverage for the services rendered. This authorization provides that Elm City Center may release objective clinical information related to my diagnoses and treatment, which may be requested by my insurance company or its designated agent.

ASSIGNMENT OF INSURANCE BENEFITS/ PAYMENT GUARANTEE/ COLLECTION FEE. I authorize payment to be made directly to Elm City Center for insurance benefits payable to me. I understand that I am financially responsible to Elm City Center for any covered or non-covered services, as defined by my insurer. I understand that if my account balance becomes overdue and the overdue account is referred to a collection agency, I will be responsible for the costs of collection including reasonable attorneys fees.

PRIVACY POLICY. I acknowledge having received Elm City Center’s, “Notice of Privacy Practices”. My rights including the right to see and copy my record, to limit disclosure of my health information, and to request an amendment to my record, is explained in the Policy. I understand that I may revoke in writing my consent for release of my health care information, except to the extent the Practice has already made disclosures with my prior consent.

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Consumer or Authorized Person Signature           Relationship                                        Date

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Witness Signature                                                       Date

Consumer unable to sign. Verbal consent given. Reason_____________________________