I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosure of my health information. I have been given a copy of your Notice of Privacy Practice prior to signing this consent. I understand that this organization has the right to change it's Notice of Privacy Practice from time to time and that I may contact this organization at any time at the address above to obtain a current copy. I understand that, under the Health Insurance Portability & Accountability Act 9f 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.