Hipaa Patient Consent Form printable pdf download

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HIPAA

PATIENT CONSENT FORM

Our Notice of Privacy Practices provides information about how we may use and disclose protected

health information about you. The Notice contains a Patient Rights section describing your rights under

the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may

change. If we change our Notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information about you is used or

disclosed for treatment, payment, or health care operations. We are not required to agree to this

restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for

treatment, payment, and health care operations. You have the right to revoke this Consent, in writing,

signed by you. However, such a revocation shall not affect any disclosures we have already made in

reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance

Portability and Accountability Act of 1996 (HIPAA).

The patient understands that:



Protected health information may be disclosed or used for treatment, payment, or health care

operations.



The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review

this Notice.



The Practice reserves the right to change the Notice of Privacy Practices.



The patient has the right to restrict the uses of their information but the Practice does not have to

agree to the restrictions.



The patient may revoke this Consent in writing at any time and all future disclosures will then

cease.



The Practice may condition receipt of treatment upon the execution of this Consent.

The Consent was signed by: __________________________________________________

Printed Name of Patient or Representative

__________________________________________________

Signature Date

Relationship to Patient

(if other than patient): __________________________________________________

Witness:

__________________________________________________

Printed Name . Practice Representative

__________________________________________________

Signature Date

Hipaa Patient Consent Form