Hipaa Patient Consent Form With Insurance Information

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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 Patient Rights section describing your rights under the law.
You have the right to review our Notice before signing the 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 operation. 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 in reliance on
your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and
Accountability Act of 1996 (HIPPA).
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 that 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 uses of their 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
Relationship to Patient
(If other than patient)
_______________________________________________
INSURANCE INFORMATION
I understand and agree that health and accident insurance policies are an agreement between an
insurance carrier and myself. Furthermore, I understand that this office will prepare any and necessary
reports and forms to assist me in a making collections from the insurance company and that any amount
to be paid directly to this office will be credited to my account upon receipt. However, I clearly
understand and agree that all services rendered to me are charged directly to me and that I am
personally responsible for payment. I also understand that if I suspend or terminate my care and
treatment, and fees for professional services rendered to me will be immediately due and payable.
Signature
Date

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