Hipaa Patient Consent Form printable pdf download

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 this 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 operations. 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 (HIPAA).

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 the 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.



The patient acknowledges that he/she has received a copy of our HIPAA practices

brochure.

The Consent was signed by: __________________________________________________

Printed Name . Patient or Representative

Relationship to Patient

(if other than patient): __________________________________________________

Witness:

__________________________________________________

Printed Name . Practice Representative

Hipaa Patient Consent Form