Annual Consent & Authorization Form

CONSENT FOR TREATMENT:

• Permission is hereby given for any drug or laboratory test, medication, or exam as may be deemed necessary by the Psychiatrist, Physician Assistant, or Nurse Practitioner.
• I understand I have the right to see a Psychiatrist if I so choose and have the right to see a Psychiatrist prior to any prescription drug or device order being carried out by an Advanced Practitioner.
• In the case of an un-emancipated minor, the consent below is being given on his or her behalf

Acknowledgement of Privacy Rights:

By signing below, I acknowledge that I am aware of Bridgepoint’s Notice of Privacy Practices and Individual Rights. We may use or share your medical information with personnel involved in your care at Bridgepoint. We may disclose your medical information to people outside of the system, such as Health Information Exchanges. Bridgepoint’s Notice of Privacy Practices contains more information about the policies and practices protecting the patient’s privacy. I acknowledge that I have read the above, am giving my consent to the above, and am acknowledging I have been informed of my rights to privacy.