Patient Hippa Consent Form

 

   

508   E .   S outh   T emple   # 114  

Salt   L ake   C ity,   U T   8 4102  

Phone   ( 801)   3 22-­‐5032       F ax   ( 801)   5 96-­‐2605

 

 

 

 

PATIENT   H IPPA   C ONSENT   F ORM  

 

I   u nderstand   t hat   I   h ave   c ertain   r ights   t o   p rivacy   r egarding   m y   p rotected   h ealth   i nformation.     T hese  

rights   a re   g iven   t o   m e   u nder   t he   H ealth   I nsurance   P ortability   a nd   A ccountability   A ct   o f   1 996   ( HIPAA).      

I   u nderstand   t hat   b y   s igning   t his   c onsent,   I   a uthorize   y ou   t o   u se   a nd   d isclose   m y   p rotected   h ealth  

information   t o   c arry   o ut:  

• Treatment,   i ncluding   d irect   o r   i ndirect   t reatment   b y   o ther   h ealthcare   p roviders   i nvolved   i n   m y  

treatment.  

• Obtaining   p ayment   f rom   t hird   p arty   p ayers   ( e.g.   m y   i nsurance   c ompany).  

• The   d ay   t o   d ay   h ealthcare   o perations   o f   y our   p ractice.  

I   h ave   a lso   b een   i nformed   o f   a nd   g iven   t he   r ight   t o   r eview   a nd   s ecure   a   c opy   o f   t he   N otice   o f   P rivacy  

Practices,   w hich   c ontains   a   m ore   c omplete   d escription   o f   t he   u ses   a nd   d isclosures   o f   m y   p rotected  

health   i nformation   a nd   m y   r ights   u nder   H IPAA.     I   u nderstand   t hat   y ou   r eserve   t he   r ight   t o   c hange   t he  

terms   o f   t his   n otice   f rom   t ime   t o   t ime,   a nd   t hat   I   m ay   c ontact   y ou   a t   a ny   t ime   t o   o btain   t he   m ost  

current   c opy   o f   t his   n otice.  

I   u nderstand   t hat   I   h ave   t he   r ight   t o   r equest   r estrictions,   i n   w riting,   o n   h ow   m y   p rotected   h ealth  

information   i s   u sed   a nd   d isclosed   t o   c arry   o ut   t reatment,   p ayment   a nd   h ealth   c are   o perations,   b ut   t hat  

you   a re   n ot   r equired   t o   a gree   t o   t hese   r equested   r estrictions.     H owever,   i f   y ou   d o   a gree,   y ou   a re   t hen  

bound   t o   c omply   w ith   t his   r estriction.  

I   u nderstand   t hat   I   m ay   r evoke   t his   c onsent,   i n   w riting,   a t   a ny   t ime.     H owever,   a ny   u se   o r   d isclosure  

that   o ccurred   p rior   t o   t he   d ate   I   r evoke   t his   c onsent   i s   n ot   a ffected.  

 

 

________________________________        

                                                                      _ ___________________________  

 

 

Signed    

 

 

 

 

 

 

Date  

 

 

________________________________  

 

                                          _ ___________________________  

 

 

 

Printed   N ame    

 

 

 

 

                            R elationship   t o   P atient