Patient Hipaa Consent Form - The Dermatology Clinic

 

 

 

PATIENT   H IPAA   C ONSENT   F ORM  

Last   U pdated:   1 0/5/2013  

 

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   r ights   a re  

given   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  

signing   t his   c onsent   I   a uthorize   y ou   t o   u se   a nd   d isclose   m y   p rotected   h ealth   i nformation   t o   c onduct:    

 

 Treatment   ( including   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-­‐to-­‐day   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   y our   N otice   o f   P rivacy   P ratices,  

which   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   h ealth   i nformation   a nd  

my   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   t erms   o f   t his   n otice   f rom   t ime   t o    

time   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   c urrent   c opy   o f   t his   n otice.   I   u nderstand   t hat   y our  

practice   m aintains   t he   m ost   u p-­‐to-­‐date   v ersion   o f   i ts   N otice   o f   P rivacy   P ractices   o n   i ts   w ebsite.   I   u nderstand   t hat   I  

have   t he   r ight   t o   r equest   r estrictions   o n   h ow   m y   p rotected   h ealth   i nformation   i s   u sed   a nd   d isclosed   t o   c arry   o ut  

treatment,   p ayment   a nd   h ealth   c are   o perations,   b ut   t hat   y ou   a re   n ot   r equired   t o   a gree   t o   t hese   r equested  

restrictions.   H owever,   i f   y ou   d o   a gree,   y ou   a re   t hen   b ound   t o   c omply   w ith   t his   r estriction.   I   u nderstand   t hat   I   m ay  

revoke   t his   c onsent,   i n   w riting,   a t   a ny   t ime.   H owever,   a ny   u se   o r   d isclosure   t hat   o ccurred   p rior   t o   t he   d ate   I  

revoke   t his   c onsent   i s   n ot   a ffected.    

 

  D ate:   _ ____/______/_____________  

 

   

Print   P atient   N ame:   _ _________________________________________    

 

   

Signature:   _ ____________________________________________________  

 

   

Relationship   t o   P atient:   _ _____________________________________  

 

 

Priya   S ivanesan,   M D,   M PH  

 241   M onmouth   R oad,   S uite   1 01      W est   L ong   B ranch,   N J   0 7764  

Phone:   7 32-­‐222-­‐2250      F ax:   8 88-­‐218-­‐8335  

 2315   R oute   3 4,   U nit   B      M anasquan,   N J   0 8736  

Phone:   7 32-­‐528-­‐0200      F ax:   8 88-­‐218-­‐8335