I hereby voluntarily consent to the rendering of such care and treatment as my providers, in their professional judgment, deem necessary for my health and well-being. 

If I request or initiate a telehealth visit, I hereby consent to participate in such telehealth visit and its recording, and I understand I may terminate such visit at any time. 

My consent shall cover the carrying out of orders of my treating provider by the clinic staff. I acknowledge that neither my provider nor any of their staff have made any guarantee or promise as to the results that I will obtain.

I consent to the use or disclosure of my protected health information by Hockanum Valley Community Council, Inc. (HVCC) to any person or organization for the purposes of carrying out treatment, obtaining payment or conducting certain healthcare operations.  Protected health information used or disclosed by HVCC may include HIV/AIDS related information, psychiatric and other mental health information and drug and alcohol treatment information, as long as such information is used or disclosed in accordance with Connecticut and Federal law, which may require you to provide specific authorization.  I understand that information regarding how HVCC will use and disclose my information can be found in HVCC’s Notice of Privacy Practices.  I understand that this consent is effective for as long as HVCC maintains my protected health information.

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