HIPPA Consent and Release Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
• The practice reserves the right to change the privacy policy as allowed by law.
• The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
• The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
• The practice may condition receipt of treatment upon execution of this consent.

HIPAA Release

Please complete all sections of this HIPAA release form. If any sections are left blank, this form will be invalid and it will not be possible for your health information to be shared as requested.

Section I

Section II

I would like to give the above healthcare organization permission to:

Form of Disclosure

Section III - Reason for Disclosure

Section IV - Who Can Receive My Health Information

Section V - Duration of Authorization

Section VI - Signataure

I understand that:

• I am permitted to revoke this authorization to share my health data at anytime and can do so by submitting a request in writing to Boston Psychiatric Alliance.
• In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data.
• I understand that I do not need to give any further permission for the information detailed in Section II to be shared with the person(s) or organization(s) listed in section IV.
• I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.

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