Emily Young

 
 GREAT VALLEY IMAGING 
 Privacy Practice Notice and Consent Form 
 Consent for use and disclosure of Protected Health Information 
 and 
 Acknowledgement of Privacy Practices 
 Purpose of Consent: By signing this form. you will consent to our use and disclosure of 
 your personal health information to carry out treatment. payment activities, and related 
 health care operations. 
 Notice of Privacy Practices: A copy of our Notice of Privacy Practices is available in our 
 office for your review upon request. 
 Patient Name: (Please print) 
 ED FOSTER 
 I understand that by signing this Consent form.
 electronically signed by: Ed Foster 
 Date: 04/10/2015
 003105 
 0031
