HIPAA Information and Consent

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy.

A Notice of Privacy Practices should be available to you in the office. The notice provides information about how we may use and disclose protected health information about you in order to carry out treatment, payment, and healthcare operations, and for other purposes permitted or required by law. The notice also contains information about your rights under the law.

Additional information is available from the U.S. Department of Health and Human Services.

By signing below, you understand and agree to the terms of our notice of privacy practices, which include:

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
• Authorization is required for certain disclosures of your Protected Health Information.
• You have the right to opt-out of fundraising communications.
• You have the right to restrict disclosures of your Protected Health Information under certain circumstances.
• You have the right to be notified of a breach of unsecured Protected Health Information.

By signing below, you understand and agree that:

• The practice has a Notice of Privacy Practices that you have had the opportunity to review.
• The practice reserves the right to change the Notice of Privacy Practices, and if we change our notice, you may obtain a revised copy by contacting our office.
• You may revoke this consent in writing at any time, and all future disclosures will cease.
• The practice may condition treatment upon the execution of this consent.

(Please Sign Below)