Hipaa Consent Form printable pdf download

Hipaa Consent Form

HIPAA CONSENT FORM

I understand that I have certain rights to privacy regarding my protected health information.

These rights are given to me under the Health Insurance Portability and Accountability Act

of 1996 (HIPAA). I understand that by signing this consent, I authorize you to use and

disclose my protected health information to carry out:

Treatment (including direct or indirect treatment by other healthcare providers involved in

my treatment); Obtaining payment from third party payers (e.g. my insurance company);

The daytoday healthcare operations of your practice.

I have also been informed of, and given the right to review and secure a copy of your Notice

of Privacy Practices, which contains a more complete description of the uses and disclosures

of my protected health information, and my rights under HIPAA. I understand that you

reserve the right to change the terms of this notice from time to time and that I may contact

you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health

information is used and disclosed to carry out treatment, payment, and health care

operations, but that you are not required to agree to these requested restrictions. However, if

you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or

disclosure that occurred prior to the date I revoke this consent is not affected.

Date: ___________________________________________

Printed Patient Name: _______________________________

Relationship to Patient: ______________________________

Signature:_________________________________________

Hipaa Consent Form