HIPAA Patient Consent & Privacy Form
Review and acknowledge your rights regarding your healthcare information and communication preferences.
Notice of Privacy Practices & Consent Summary
I acknowledge that I have reviewed the Notice of Privacy Practices. I understand that this notice may change and I will be informed of updates at my next visit. I understand that my protected health information may be used or disclosed for treatment, payment, or healthcare operations. I understand that the practice may restrict use/disclosure but is not required to agree. I understand that I may revoke this consent in writing, and that revocation is not retroactive. I understand that treatment may be conditioned on the execution of this consent. I also understand that my health information may be used anonymously in a publication.
May we phone, email, or text you to confirm appointments?
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Yes
No
May we leave messages on your answering machine, home, or cell phone?
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Yes
No
May we discuss your medical condition with any member of your family?
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Yes
No
If yes, please list the approved family members:
Printed Name of Person Signing
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Signature of Person Signing
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Date of Signature
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Month
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Day
Year
Date
Witness Name
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Witness Signature
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Date (Witness)
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Month
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Day
Year
Date
Acknowledge and Submit
Acknowledge and Submit
Should be Empty: