PATIENT RECORD OF DISCLOSURES / HIPAA PATIENT CONSENT FORM
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information (PHI) about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing the Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.
You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, if you revoke this Consent it shall not affect any disclosure we have already made in reliance on your prior Consent.
The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The patient understands that: • Protected health information may be disclosed or used for treatment, payment, or health care operations. • The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice. • The Practice reserves the right to change the Notice of Privacy Practices • The patient has the right to restrict the uses of their information, but the Practice does not have to agree to those restrictions. • The patient may revoke this Consent in writing at any time and all future disclosures will then cease. • The Practice may condition receipt of treatment upon the execution of this Consent. In general, the HIPPA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI is made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.

Release of Information