Patient Authorization Form printable pdf download

Patient Authorization Form

Dr. Christopher J. Bott

Causeway Chiropractic

382 West 9

Street, Suite 8

Ship Bottom, New Jersey 08008

609-361-1800

FAX 609-361-8400

Patient Authorization Form

I understand that I have certain rights to privacy regarding my 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 Causeway

Chiropractic and Dr. Christopher J. Bott to use, obtain and disclose my protected health

information to perform:

 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 daily healthcare operations of the practice.

I have been informed and given the right to review a copy of your Notice of Privacy

Practices. This document contains a complete description of the uses and disclosures of

my protected health information and my rights under HIPAA.

I understand that

Causeway Chiropractic and Dr. Christopher J. Bott reserve the right to change the terms

of this notice to comply with updated privacy laws.

I may contact Causeway

Chiropractic at any time to obtain a current copy of this notice.

I understand that I may revoke this consent, in writing, at any time. Any use or

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

Print Patient Name: _____________________________________

Relationship to Patient:

___ Self ___ Parent ___ Guardian

I hereby acknowledge that I am informed of my rights under the Health Insurance

Portability and Accountability Act of 1996 (HIPAA) and have been given the opportunity

to ask any questions I may have regarding this notice.

I hereby authorize Causeway Chiropractic and Dr. Christopher J. Bott to disclose my

protected health information to the following individual:

Name: _____________________________ Relationship: ______________________

Signature: ____________________________________ Date: ___________________

Patient Authorization Form