Personal Health Information Release Form (HIPAA Release Form)

Name: Date of Birth:

Messages
Please call ; ; Number:

If unable to reach me:


The best time to reach me is (day) between (time)

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

The patient understands that:

  • Protected health information may be disclosed or used for treatment, payment or health care operations
  • The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice and request a copy
  • The Practice reserves the right to change the Notice of Privacy Policies
  • The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions
  • The patient may revoke this Consent in writing at any time and all future disclosures will then cease
  • The practice may condition treatment upon the execution of this Consent.

I understand that this office will try to accommodate my wishes about my contact information, but may have to contact me at the other numbers if unable to contact me at my requested number/location.

Signed: Date:
Witness: Date:

IMPORTANT: PLEASE COPY OR WRITE THE FOLLOWING DOWN: n92r6d00
THIS IS THE PASSWORD TO UNZIP YOUR FORMS. YOU WILL BE UNABLE TO ACCESS THEM WITHOUT IT.


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