Hipaa Patient Consent Form - Unique Dermatology Wellness
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2HIPAA PATIENT CONSENT FORM
The federal government requires all medical offices to make patients aware that they have
rights regarding the use of their personal health information. A copy of our Notice of Privacy Practices
is available for your review at the front desk.
By signing this form, you consent to our use and disclosure of protected health information
according to the Notice of Privacy Practices available to you at our front desk. You have the right to
revoke this consent at any time, in writing. However, such a revocation shall not affect any disclosures
we have already made in reliance on your prior consent. Unique Dermatology & Wellness Center
provides this form to comply with the Health Insurance Portability and Accountability Act of 1996
(HIPAA).
You have the right to request a restriction or limitation on the medical information we use or
disclose about you for treatment, payment or health care operation. This request must be done in
writing. Whenever possible we will honor your request.
The patient understands that:
We will not release information to any future doctor, attorney, life insurance company,
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workman’s comp company without your written consent.
Protected health information may be used for treatment through one of you current doctors,
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payment with your insurance company or healthcare operations within our office.
Unique Dermatology & Wellness Center has a Notice of Privacy Practices that is available for
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review.
Unique Dermatology & Wellness Center reserves the right to change the Notice of Privacy
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Practices.
The patient has the right to restrict the use of their information, but Unique Dermatology &
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Wellness Center does not have to agree to these restrictions if, for example it interferes with
payment, daily operations or providing quality health care.
The patient may revoke this consent in writing at any time and all future disclosures will then
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cease.
Unique Dermatology & Wellness Center may condition treatment upon the execution of this
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consent.
You have the right to be notified of a protected health information breach
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Unique Dermatology & Wellness Center cannot sell your health information without your
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permission.
Certain uses of your medical data, such as use of patient information in marketing, require
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prior disclosure and your authorization. Uses and disclosures not described in the Notice of
Privacy Practice will only be made with your authorization.
I acknowledge that I was provided with a copy of the Notice of Privacy Practices.
Patient (Print Name):__________________________________
Date:______________________
Patient (Signature):_______________________________ Relationship to Patient:__________________
FOR OFFICE USE ONLY
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