CONSENT FOR THE USE AND DISCLOSURE OR PHI AUTHORIZATION*
I give consent to XTC Hair Growth Systems to use and disclose my patient health information for treatment, payment, and healthcare operations as permitted under the Privacy Regulations of H.I.P.A.A. For detailed information about our privacy practices, XTCTM general policies and practices please refer to the privacy and practices notice issued to you and/or review the notice posted near the reception desk.
I have received a copy of XTC Hair Growth System’s Privacy and Practices Notice. You may request an additional copy at any time.
You have the right to request restrictions on the uses and disclosures of your patient information. However, we are not required to agree to the patients’ request. If we do agree to the request, the restriction is binding and will only be granted in writing.
You have the right to revoke the consent and authorization in writing.
Please give us a 4 hour notice or you will be charged a $25 no-show fee.
Today's Date: March 29, 2023