HIPAA Form for Patients 18+ Years

Patient Consent for Use and Disclosure of Protected Health Information & Receipt of Practice Privacy Policy (18+ Years)

ABC Pediatrics • 5333 W. University Drive, McKinney, TX 75071 • (972) 569-9904
Patient Name*
Patient Date of Birth*

MonthDayYear
Date
I hereby give my consent for ABC Pediatrics to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). ABC Pediatrics’ Notice of Privacy Practices provides a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. ABC Pediatrics reserves the right to revise its Notice of Privacy Practices at any time. A copy of the Notice of Privacy Practices may be obtained at any time by forwarding a written request to ABC Pediatrics’ Privacy Officer at 5333 W. University Drive McKinney, TX 75071.

By signing this form, I acknowledge receipt of the office Notice of Privacy Practices. I also consent to allowing ABC Pediatrics to call, email, fax or mail my home or any other alternative contact point I provide and leave a message on voice mail, in person or in writing, in reference to any items that assist the Practice in carrying out TPO, such as appointment reminders, insurance issues, and clinical care (including testing results). I understand that I have the right to request that ABC Pediatrics restricts how it uses or discloses my PHI to carry out TPO. The practice does not have to agree to my requested restrictions, but if it does, it is bound by the agreement. All requests for restrictions must be submitted in writing.

I may revoke my consent in writing except to the extent that the Practice has already made disclosures in reliance upon my prior consent. I understand that if I do not sign this consent, or later revoke it, ABC Pediatrics may decline to provide treatment to me.
HIPAA Approved Contacts

By adding names to this form, I agree that they are allowed to receive PHI in the same manner as described above (with the exception of information relating to STD, HIV/AIDS, Pregnancy testing and records relating to drug, alcohol or mental health treatment which all require an additional release).
Contact Name
Relationship to Patient
Contact Name
Relationship to Patient
Contact Name
Relationship to Patient
Patient Portal

Now that you have turned 18, you get to choose who may have access to your medical information. By providing an email address below, you will receive access to your online patient portal account. You must create your own account before adding parents/guardians/etc. as proxies, and you must add them to your account yourself.
Patient Email Address*
example@example.com
Patient Phone Number*
Please enter a valid phone number.
Consent and Signature

I understand that I may change the above information at any time by sending my written request to my physician. Any change requested does not affect any communication previously made in reasonable reliance on this form.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Patient Consent for Use and Disclosure of Protected Health Information & Receipt of Practice Privacy Policy (18+ Years)

HIPAA Approved Contacts

Patient Portal

Consent and Signature