Hipaa Consent Form printable pdf download

Ashburn Farm Dental Arts

Landmark Smile

43330 Junction Plaza, Suite 122

5249 Duke Street, Suite 406

Ashburn, VA 20147

Alexandria, VA 22304

(703) 729- 7900

(703) 370-6800

HIPAA CONSENT FORM

The Health Insurance Portability and Accountability Act (HIPAA) provide safeguards to protect your privacy.

Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been practiced

for years. This form is a “friendly” version. A more complete text is available in the office.

What this is all about: Specifically there are rules and restrictions on who may see or be notified of your Protected

Health Information (PHI). These restrictions do not include normal interchange of information necessary to provide

you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these

needs with our goal of providing you with quality professional service and care. Additional information is available

from the U.S. Department of Health and Human Services.

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We have adopted the following policies:

1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all

administrative matters related to your care are handled appropriately. This specifically includes the sharing

of information with your healthcare providers, laboratories, health insurance payers as is necessary and

appropriate for your care. Patient files may be stored in the open files racks and will not contain any coding

which identifies a patient’s condition or information which is not already a matter of public record. The

normal course of providing care means that such records maybe left, at least temporarily, in administrative

areas such as the front desk, examination room, etc. Those records will not be available to persons other

than office staff. You agree to the normal procedures utilized within the office for handling of charts,

patient’s records, PHI, and other documents or information.

2. It is office policy to remind patients of their appointments. We may do this by telephone, email, US mail or

by any other means convenient for the practice and/or as required by you. We may send you other forms of

communications informing you of changes to the office policy and new technology that you might find

valuable or informative.

3. The practice utilizes a number of vendors in the conduct of business; these vendors may have access to PHI

but must agree to abide by the confidentiality rules of HIPAA.

4. You understand and agree to inspections of the office review of documents which may include PHI by

government agencies or insurance payers in normal performances of their duties.

5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or

the doctor.

6. Your confidential information will not be used for the purposed of marketing or advertising of products,

goods or services.

7. We agree to provide patients with access to their records in accordance with state and federal laws.

8. We may change, add, delete of modify any of these provisions to better serve the needs of both the

practice and the patient.

9. You have the right to request restrictions in the use of your protected health information and to request

change in certain policies used within the office concerning your PHI. However, we are not obligated to

alter internal policies to confirm your request.

I, (Name) _______________________________, on (Date) _____/_____/_____ do hereby consent and

acknowledge my agreement to the terms set forth in the HIPAA information form and sequent changes in

the office policy. I understand that this consent shall remain in force this time forward.

Hipaa Consent Form

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