Patient Consent Form:
The department of health and human services has established a “Privacy Rule”, to ensure that personal health care
information is protected. The Privacy Rule was also created to provide a standard for certain health care providers to
obtain their patient’s consent for use and disclosure of health information about the patient to carry out treatment,
payment, or health care operations.
As our patient we want you to know that we respect the privacy of your personal medical records and will do all we can to
secure and protect that privacy. We strive to always take responsible precautions to protect your privacy. When it is
appropriate and necessary, we provide the necessary information to only those we feel need your health care information
about treatment, payment, or health care operations, to provide health care that is in your best interest.
We also want you to know that we support your full access to your medical records, with the appropriate HIPPA compliant, signed documentation. We may have indirect treatment relationships with you (such as laboratories that only
interact with physicians and not patients) and may have to disclose personal health information about treatment, payment,
or health care operations. These entities are most often not required to obtain patient consent.
You may refuse to consent to the use of disclosure of your personal health information, but this must be in writing. Under
this law, we have the right to refuse service to treat you, should you choose to refuse to disclose your personal health
information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or
part of your PHI. You may not revoke actions that have already been taken which relied in this or previously signed
If you have any objections to this form, please feel free to ask to speak with our HIPPA Compliance Office. You have the
right to review our privacy notice, to request restrictions and revoke consent in writing after you’ve reviewed our policy
Thank you for being one of our valued Patients.