HIPPA Notice of Privacy Practices Acknowledgement of Receipt

By registering for an appointment on this website, I herby acknowledge that I have read and understand the privacy practice notice and may obtain additional copies upon my request. This acknowledgement will be filed with my records. Authorization for release of confidential records.

I hereby authorize Mary Jane Wellness Clinic to disclose and verify me as a patient to any law enforcement agency, my Physican(S), Child Protective Services or any state approved Florida dispensary. This is valid during the period for which the recommendation has been issued. This consent is subject to written revocation only, at any time expect to the extent that action has already been taken based on this consent.

I give my permission for my medical records and file to be reviewed by another physician working with Mary Jane Wellness Clinic .

I understand that this might happen if the original doctor that evaluated me needs a secondary opinion, is not available, off premise, has moved or terminated His/Her practice. I will ask the doctor all questions regarding my treatment before the completion of my appointment.