Patient Consent Form/HIPPA
The Department of Health Services has established a “Privacy Rule” to help insure that personal
information is protected or privacy. The Privacy rule was also created in order to provide a standard for
certain health care providers to obtain their patients consent for uses and disclosures of health
information about the patient to carry out treatment, payment or health care operations.
As our patient we want you to know that we respect the privacy of your personal medical care
and will do all we can to secure and protect that privacy. We strive to always take responsible
precautions to protect that privacy. When it is appropriate and necessary we provide the minimum
necessary information about treatment, payment or health care operations in order to provide health
care that is in your best interest.
We also want you to know that we support your full access to your medical records. We may indirect
treatment relationships with you (such as laboratories the only interact with physicians and not
patients) and may have to disclose personal health information for purpose of treatment or health care
operations. These entities are most often not required to obtain patient consent.
You may refuse to consent to the use o discloser of your personal health information but this
must be in writing. Under this law we have the right to refuse to treat you should you choose to refuse
to disclose your personal health information (PHI). If you choose to give consent in this document at
some future time you may request all or part o your (PHI). You may not revoke actions that have
already been taken which relied on this or a previously signed consent.
I you have any objections to this form please ask to speak with our HIPPA Compliance Officer. You have
the right to review our policy notice to request restrictions and revoke consent in writing after you
reviewed out policy notice.
Print Name:_____________________________
Signature: ________________________
Date of Birth: _____________________
May we leave message on your answering machine or with a family regarding appointment and
reminders or request for you to call the office? YES ______ NO __________
Signature: ___________________________
Date: _____________________________