The medical privacy Notice of Robert Weaver provides information about how we may use and disclose confidential medical information about you. You have the right to read our Notice before signing this Consent. The terms of our Notice may change from time to time. If we change our Notice, you may obtain a revised copy during your next visit.

By signing this Authorization, you agree to let us use and disclose confidential medical information about you for treatment, payment, and health care operations. This includes information about physical and mental illness, substance abuse or HIV/AIDS, if applicable. You are also consenting to release of medical information about you to any insurer, third party payer, the Social Security Administration, or any agents or consultants who help this office get paid for your treatment and other health care operations.

Date_____________________ Patient Name____________________________________

Patient Signature__________________________________________________________

Patient's Legal Representative________________________________________________