Patient Consent Form

I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), I have certain

rights to privacy regarding my protected health information. I understand that this information can and will be

used to: 

                                   * Conduct, plan, and direct my treatment and follow-up among multiple healthcare providers

                                     who may be involved in my treatment either directly or indirectly.

                                   * Obtain payment from third-party payers.

                                   * Conduct normal healthcare operationas such as quality assessment and 

                                      physician certifications.

I have been informed by you and your NOTICE OF PRIVACY PRACTICES containing a more complete description

of the use and disclosures of my health information. I have been given the right to review such NOTICE OF 

PRIVACY PRACTICES prior to signing this consent.  I understand that this organization hs the right to change

its NOTICE OF PRIVACY PRACTICES from time to time and that I may contact this organization at any time 

to obtain a current copy of the NOTICE OF PRIVACY PRACTICES. 

I understand that I may request in writing that you restrict how my private information is used or disclosed

to carry out treatment, payment, or health care operations. I also understand that you are not required to

agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have

taken action relying on this consent. 

I authorize your office to disclose only the specific information below, only for the purposes and parties

described below. I may revoke this authorization in writing by contacting your office. Please list names

and phone numbers of anyone who you would like us to share your medical information with (this

includes information regarding treatment, account balance, appointment time and date, etc.):

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

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I 

________________________________________                                 ________/________/__________

Signature of patient or guardian                                                             DATE

_______________________________________

Patient name