HIPAA Compliance Patient Consent Form

 

* 1. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by choosing YES you have reviewed the below notice.

The terms of the notice may change, if so, you will be notified and will be required to consent with any updates if necessary. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By choosing YES below, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form and choosing YES, I understand that:

  • Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
  • The practice reserves the right to change the privacy policy as allowed by law.
  • The practice has the right to restrict the use of the information but the practice does not have to agree to those
  • restrictions.
  • The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
  • The practice may condition receipt of treatment upon execution of this consent.

* 2. This consent was signed by:

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