This notice describes how your health information may be used and disclosed and how you can get access to this information. Your privacy is important. Please review this information carefully.
This form authorizes ARHC to disclose your information to parties that require that information to perform your procedure.
If the cardholder cannot be present on the appointment day, they must complete this form, make a copy of both sides of the card and their photo ID. The patient must bring the completed form and the copies on the day of the appointment.