Informed Consent for HIPAA

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

⦁ Treatment (including direct or indirect treatment by other healthcare providers involved in my
treatment).
⦁ Obtaining payment from third party payers (e.g. my insurance company).
⦁ Making and reminding you of appointments by telephone, postcards, e-mail and letters.

I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosure of my rights under HIPPAA. I understand that I have the right to request restrictions. In addition, I understand that I have the right to allow people to have access to my health information. (Please list names below):

People Who have a right to my Health Information:

Your Name (required)

Your Date of Birth (required)

I Understand and Agree (required)