Hipaa Patient Consent Form printable pdf download

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

care operations.

 The Practice has a Notice of Privacy Practices and the patient has the opportunity to review

this Notice.

 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

then cease.

 The Practice may condition receipt of treatment upon the execution of this Consent.

This consent was signed by: ________________________________________________

(Printed Name, Patient or Representative)

________________________________________

Signature

_______________________

Date

Hipaa Patient Consent Form