HIPAA

Please read over our office HIPAA Private Policies notice and sign below.

HIPAA

I have received a copy of this office’s Notice of Private Policies and give this practice permission to use or disclose my protected health information to carry out my treatment to obtain payment from my insurance companies and for health care operations like quality reviews. I understand the practice has the right to change their privacy practices and that I may obtain revised notices at the practice.  I understand that I have a right to request restriction of how my protected health information is used but that the practice is not required to agree to the request.  I also understand that I may revoke this consent at any time by making a request in writing except for information that has already been used/disclosed.