Additional uses for which I must give my authorization:


I understand that Metroplex Women’s Clinic (MWC)/Metroplex Mobile Pregnancy Clinic (MMPC) may use my Protected Health Information for the following reasons: treatment, healthcare operations, as business associates, to contact you and as required by state or federal law. (I may opt out of this authorization) Special authorization is required.


I understand that I may revoke this authorization at any time by notifying MWC/MMPC in writing. However, if I choose to do so, I understand that my revocation will not affect any actions taken by MWC/MMPC before receiving my revocation.


MWC/MMPC reserve the right to change the Notice of Privacy Practices as necessary. The most current Notice will be placed on display in the center at all times.

This day and moment
belong to you.