HIPAA Acknowledgement and Consent Form

Consent*

I understand that under the Health Insurance Portability and Accountability Act of 1996(HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: •Conduct, plan and direct my treatment and follow-up care among the multiple healthcareproviders who may be involved in that treatment directly or indirectly.*

• Conduct, plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly.
• Obtain payment from designated third-party payers.
• Conduct normal health care operations such as quality assessments or evaluations and physician certifications.

Consent*

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information (available in the office in print form). I have reviewed such Notice of Privacy Practices prior to signing this consent, and acknowledge that I have studied the Privacy Practices prior to signing this consent, and acknowledge that I have studied the Privacy Practices. I understand that this organization has the right to change its Notice of Privacy Practices from time to time, and that I may contact this organization at any time at the address above to obtain a current copy of the Notices of Privacy Practices. *

Consent*

I understand that I may request in writing that this organization restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand the organization is not required to agree to my requested restrictions, but if the organization does agree, then it is abound to abide by such restrictions.*

Consent*

I understand that I may revoke this consent in writing at any time, except to the extent that the organization has taken action relying on this consent.*

Patient's Name*

First Last

Date*

Signature*

Legal Representative*

First Last

Relationship to Patient*

HIPAA Acknowledgement and Consent Form

HIPAA Acknowledgement and Consent Form

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