Patient HIPAA

  • PATIENT AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

    I understand that as part of my health care, the practice originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:

    • A basis for planning my care and treatment.
    • A means of communication among the health professionals who contribute to my care, such as referrals.
    • A source of information for applying my diagnosis and treatment information to my bill.
    • A means by which a third-party payer can verify that services billed were actually rendered.
    • A tool for routine healthcare operations, such as assessing quality and reviewing the competence of staff

    We can provide you with a “Notice of Patient Privacy Practices” that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

    • The right to restrict or revoke the use or disclosure of my health information for other uses or purposes.
    • The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations.
  • Restrictions

  • (Example: spouse (name), children (name(s), other relatives (name(s), friends or caregivers (name(s))
  • I understand that as part of treatment, payment, or healthcare operations, it may become necessary to disclose health information to another entity, i.e., referrals to other healthcare providers. I consent to such disclosure for these uses as permitted by law.

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