Your Privacy Matters
The HIPAA Privacy Rule establishes national standards to protect individuals' medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically.
HIPAA Compliance Disclosure
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. This notice is for your information only. Your signature signifies that you have reviewed our notice before signing consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. 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 (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. Upon signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. A copy of this disclosure must be signed.
Upon signing, You understand that:
Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
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 (You) has/have the right to revoke this consent in writing at any time and all full disclosures will then cease.
The practice may condition receipt of treatment upon execution of this consent.
Your personal and medical information will not be shared without your knowledge and consent. Your information will not be used for anything other than documenting treatment progress and providing client care.