Patient Consent Form
Patient Consent For Use And Disclosure Of Individually Identifiable Heath Information


With my consent, Dr. Cheryl L. Howard may use and disclose individually identifiable health information (IIHI) about
me to carry out treatment, payment, healthcare operations (TPO), education and training, appointment reminders,
treatment alternatives, and health related benefits and services. Please refer to Dr. Cheryl L. Howard's Notice of
Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent.
Dr. Cheryl L. Howard reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of
Privacy Practices may be obtained by forwarding a written request to Dr. Cheryl L. Howard's  Privacy Officer at
4219 Richmond, Ste. 110, Houston, Texas 77027.

With my consent, Dr. Cheryl L. Howard may call my home or other designated location and leave a message on
voice mail or in person in reference to any items that assist the practice in carrying out TPO, education and
training, treatment alternatives, and health related benefits and services, such as appointment reminders,
insurance items and any call pertaining to my clinical care, including laboratory results among others.

With my consent, Dr. Cheryl L. Howard may mail to my home or other designated location any items that assist the
practice in carrying out TPO, educational training, treatment alternatives, and health related benefits and services,
such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.

I have the right to request that Dr. Cheryl L. Howard restrict how she uses or discloses my IIHI to carry out TPO,
educational training, treatment alternatives, and health related benefits and services. However, the practice is not
required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to Dr. Cheryl L. Howard's use and disclosure of my IIHI to carry out TPO,
educational training, treatment alternatives, appointment reminders, and health related benefits and services.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance
upon my prior consent. If I do not sign this consent, Dr. Cheryl L. Howard may decline to provide treatment to me.


__________________________________________  ____________________________________
Signature of Patient or Legal Guardian                         Print name of Patient of Legal Guardian


_______________________________
Date of Signature
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