HIPAA Information and Patient Privacy Consent
Our Notice of Privacy Practices provides information about how we (“the Practice”) may use and disclose protected health information about you (aka “Patient”). The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change, and if so, you may obtain a revised copy by contacting our office.
You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.
By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. Recovery Soldiers Ministries provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The patient understands that:
- Protected health information may be disclosed or used for treatment, payment or health care operations.
- All other disclosures by Recovery Soldiers Ministries will require specific authorization by you unless required by law.
- Recovery Soldiers Ministries has a Notice of Privacy Practices and that the patient can review this Notice and receive a copy.
- Recovery Soldiers Ministries reserves the right to change the Notice of Privacy Policies. The new policy will be available upon request from our office.
- You have the right to restrict the uses of their information used for treatment, payment or operations, but the Practice does not have to agree to those restrictions.