The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy.
Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice
for years. This form is a “friendly” version. A more complete text is posted in the office.
What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health
Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with
office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal
of providing you with quality professional service and care. Additional information is available from the U.S. Department
of Health and Human Services. www.hhs.gov
We have adopted the following policies:
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.
do hereby consent and acknowledge
my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes
in office policy. I understand that this consent shall remain in force from this time forward.
Your information will be encrypted.