Patient Hipaa Consent Form printable pdf download

Rose Optical

3300 Godfrey Road

Godfrey, IL 62035

PATIENT 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 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 authorize ________________________________ to obtain information about my healthcare.

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 ______________ 20_____________.

Print Patient Name ____________________________________

Signature ___________________________________________

We want to make sure that all our patients get the best possible care possible. We would like you to tell us your

racial/ethnic background so that we can review the treatment that all patients receive and make sure that everyone

gets the highest quality of care.

Ethnicity Are you:

Race Are you:

Hispanic or Latino

American Indian/Alaska Native

Not Hispanic or Latino

Asian

Declined

Caucasian

Black or African American

Native Hawaiian or other Pacific Islander

Language:

Declined

English

French

Spanish

Declined

Patient Hipaa Consent Form