I, ____________________________________, hereby authorize Dr. Armen A. Kassabian to use and/or disclose my health insurance information which specifically identifies me or which can reasonably be used to identify me to carry out my treatment, payment, and health care operations. I understand that while this consent is voluntary, if I refuse to sign this consent, Dr. Kassabian may refuse to treat me.

I have received a copy of the notice of privacy standards which more fully describes the uses and disclosures that can be made of my individually identifiable health information for treatment, payment, and health care operations.

I understand that I may revoke this consent at any time by notifying Dr. Kassabian in writing but if I revoke my consent, such revocation will not affect any actions that Dr. Kassabian took before receiving my revocation.

I understand that Dr. Kassabian has reserved the right to change his privacy practices and that I can obtain such changed notice upon request.

I understand that I have the right to request that Dr. Kassabian restrict how my individually identifiable health information is used and/or disclosed to carry out treatment, payment, or health operations. I understand that Dr. Kassabian does not have to agree to such restrictions, but that once such restrictions are agreed to, Dr. Kassabian must adhere to such restrictions.

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Signature of Patient or Patient's Representative Date

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Patient Name or Patient Representative's Name