HIPAA Consent Form

Downtown Dermatology

Please correct the errors described below.

This consent form allows Gilberto Alvarez del Manzano Dermatology PLLC to use and disclose information about me protected under the Health Insurance Portability and Accountability Act of 1996. This information may be used or disclosed to carry out treatment, payment or health care operations.

Gilberto Alvarez del Manzano Dermatology PLLC has provided me with a Notice of Privacy Practices, which more completely describes such uses and disclosures. it provided this notice prior to my signing the form in accordance with my right to review its practices before signing consent.

I understand that the terms of the Notice of Privacy Practices may changes and that I may obtain revised notices by mail or by an update on our website.

I understand that I have the right to request, now and in the future, how protected health information is used or disclosed to carry out treatment, payment and health care operations. I understand that while Gilberto Alvarez del Manzano Dermatology PLLC is not required to agree to my restricted restrictions, if it does agree, it is bound by that agreement.

I understand that at any time I have the right to revoke this consent provided that I do so in writing, but that the service may still use information to complete any actions that it began prior to my revoking consent and which rely on my protected information.

I understand that Gilberto Alvarez del Manzano Dermatology PLLC may refuse me further service if I revoke the consent.

I request that Gilberto Alvarez del Manzano Dermatology PLLC have access to my medical records, information on my condition, and any of my protected health information .

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.

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