HIPAA

Notice of Privacy Practice Acknowledgement and Consent

Please correct the errors described below.

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information (PHI). I understand that this information can and will be used to:

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly or indirectly.
  • Obtain payment from third-party payers.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.

I have read and understand the Notice of Privacy Practices which contain a complete description of the uses and disclosures of my health information. I understand this office has the right to change its Privacy Practices from time to time and I may obtain a current copy. Also, I understand I may revoke this Consent in writing at any time. Upon written receipt and confirmation, it shall be revoked.

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

Your information will be encrypted.

Loading...