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When you sign this consent document, you signify that you agree that we can and will use and disclose your health information to treat you, to obtain payment for our services, and to perform health care operations. You agree to pay for any provided services not covered by your insurance. You can revoke this consent in writing at any time, unless we have already treated you, sought payment for our services, or performed health care operations in reliance upon our ability to use, or disclose your health information in accordance with this consent. You have the right to ask us to restrict the use, or disclosures made for purposes of treatment, payment, or health care operations, but as described in our Notice of Privacy Practices, we are not obliged to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.