Notice of Privacy Practices and Patient Consent For Use and Disclosure of Protected Health Information  

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain patient rights regarding my protected health information.

I understand that Braun Dermatology & Skin Cancer Center P.C.. may use or disclose my protected health information for treatment, payment, or health care operations—which means for providing health care to me, the patient; handling billing and payment; and taking care of other health care operations. Unless required by law, there will be no other use or disclosure of this information without my authorization.

Braun Dermatology & Skin Cancer Center P.C. has a detailed document called the ‘Notice of Privacy Practices’. It contains a more complete description of my rights to privacy and how the office may use and disclose protected health information.

I understand that I have the right to read the ‘Notice’ before signing this agreement. If I ask, Braun Dermatology & Skin Cancer Center P.C. will provide me with the most current Notice of Privacy Practices.

My signature below indicates that I have been given the chance to review the Notice of Privacy Practices and that I agree to allow Braun Dermatology & Skin Cancer Center P.C. to use and disclose my protected health information to carry out treatment, payment, and health care operations. I have the right to revoke this consent in writing at any time, except to the extent that Braun Dermatology & Skin Cancer Center P.C. has taken action relying on this consent.