Patient HIPPA Consent Form

Please correct the errors described below.

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPPA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

  • Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
  • Obtaining payment from third party payers (e.g. my insurance company)
  • The day-to-day healthcare operations of our practice

I have also been informed of an given the right to review and secure a copy of our Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my right under HIPPA. I understand that you reserve the right to change the terms of this from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restriction on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, i you do agree you are bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not effected.

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

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