HIPAA Compliance Patient Consent Form

Protected Health Information Privacy Practices

This consent form outlines our standards and your rights concerning the storage, usage, and disclosure of your protected health information (PHI) in compliance with the Health Insurance Portability and Accountability Act (HIPAA).

•Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.
•The notice contains a patient’s rights section describing your rights under the law. You ascertain by your consent that you have reviewed our notice before agreeing to this consent.
•The terms of the notice may change. If so, you will be notified at your next visit or portal login to update your agreement.
•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 law allows for the use of the information for treatment, payment, or healthcare operations.
•By signing/agreeing to this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a clinical publication. You have the right to revoke this consent in writing. However, such a revocation will not be retroactive.

By agreeing to this form, 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 future disclosures will then cease.
•The practice may condition receipt of treatment upon the execution of this consent form.
•All protected health information (PHI) will be safeguarded using industry-standard administrative, physical, and technical controls.
•You have the right to inspect, copy, or request amendments to your health records in accordance with federal guidelines.
•Any complaints regarding the handling of your privacy practices may be filed directly with our Privacy Officer or the Department of Health and Human Services (HHS).

This is an informational privacy disclosure. Checking the agreement box on the checkout page indicates that you have read, understood, and consented to our HIPAA privacy practices.