HIPAA Patient Consent Form
Our Notice of Privacy Practices provides information about how we may use and
disclose protected health information about you. The Notice contains a Patients' Rights section
describing your rights under the law. You have the right to review our Notice before signing this
Consent. The terms of our Notice may change. If we change our Notice, you may obtain a
revised copy by contacting our office.
You have the right to request that we restrict how protected health information about
you is used or disclosed for treatment, payment, or health care operations. We are not required
to agree to this restriction, but if we do, we shall honor that agreement.
By signing this form, you consent to our use and disclosure of protected health
information about you for treatment , payment, and health care options. You have the right to
revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any
disclosures we have already made based on you prior Consent. The Practice provides this form
to comply with the Health Insurance Portability ad Accountability Act of 1996 (HIPAA).
The Patient Understands that:
Protected health information may be disclosed or used for treatment, payment, or health
The Practice has a Notice of Privacy Practices and the patient has the opportunity to review
The Practice reserves the right to change the Notice of Privacy Practices.
The patient has the right to restrict the use of thier information but the Practice does not
have to agree to those restrictions.
The patient may revoke this consent in writing at any time and all future disclosures will
The Practice may condition receipt of treatment upon the execution of this Consent.
This consent was signed by: ________________________________________________
(Printed Name, Patient or Representative)