HIPPA Compliance Patient Consent Form
Our Notice of Privacy Practices prvodies information about how we may use or disclose protected health information. The notice contains a patient's rights section section describing your rights under hte law. You ascertain that by your signature that you have reviewd 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 restrictions, but if we do, we shall honor this aggrement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information of the information for treatment, payment, or healthcare operations.
By Signing this form, I understand that:
Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The pratice has the right to restrict the use of the information but the pratice 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.