Patient Consent Form (Hipaa) printable pdf download

Patient Consent Form (Hipaa)

PATIENT CONSENT FORM

(HIPAA)

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), and

∙ Day-to-day 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.

Signed this ____ day of ________________, 2016

Print Patient Name: ________________________________________

Relationship to Patient: _____________________________________

Signature: ________________________________________________

James Lutonsky, DDS

1007 Longmire Road - Conroe, Texas

77304

Patient Consent Form (Hipaa)