Patient Hipaa Consent Form printable pdf download

PATIENT HIPAA CONSENT FORM

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

(PHI). 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 Focal Point Vision 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 (i.e. my insurance company):

The day to day healthcare operations of your practice

I have also been informed of and given the right to review a secure copy of Focal Point Vision's

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

Focal Point Vision reserves the right to change the terms of this notice from time to time and

that I may contact them 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 PHI is used and disclosed to

carry out treatment, payment, and healthcare 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 of

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

Signed this _____day of ______________________20_____.

Printed Patient Name ____________________________________________________________

Signature ______________________________________________________________________

Relationship to Patient ___________________________________________________________

Patient Hipaa Consent Form