Hipaa Consent Form - Hearts For Hearing

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HIPAA Consent Form
The Health Insurance Portability and Accountability Act of 1996 (HIPAA), established a
Privacy Rule to help insure that personal health care information is protected for 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 records and will do all we can to secure and protect that privacy. We strive to
always take reasonable precautions to protect your privacy. When it is appropriate or
necessary, we provide the minimum necessary information only to those we feel are in
need of your health care information regarding treatment, payment or health care
operations, in order to provide health care that is in your best interest.
We fully support your access to your personal medical records. We may have indirect
treatment relationships with you (such as laboratories that only interact with the
physician and not patients), and may have to disclose personal health information for
purposes of treatment, payment or health care operations. These entities are most
often not required to obtain patient consent.
You may refuse to consent to the use or disclosure of your personal health information,
but this must be done 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. If you
choose to give consent in this document, at some future time you may request to refuse
all or part of your Personal Health Information. You may not revoke actions that have
already been taken which relied on this or a previously signed consent.
If you have any objections to this form, please ask to speak with our HIPAA Compliance
Officer. You have the right to review our Privacy Notice (Compliance Assurance
Notification to Our Patients), to request restrictions and revoke consent in writing.

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