HIPAA Privacy Form
(Initials)
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This is to inform you that due to Federal Law (HIPAA), effective April 15, 2003, we may only release medical information to the following:
1.) Healthcare providers involved in your care
2.) Insurance companies to secure payment
3.) Laboratories involved in your care
4.) Attorneys with your permission
By HIPAA standards, we are not allowed to discuss your medical problems with your spouse, significant other, or adult children. Please indicate if you would like us to speak with your spouse/significant other, or adult child if and when the need arises. Note: if you decide to revoke your permission at any time, we will need a written revocation. YES, you have my permission to discuss any medical matters pertaining to my health with:
(name of person, please print)
(phone number of person)
relationship
(name of person, please print)
(phone number of person)
relationship
(name of person, please print)
(phone number of person)
relationship
(name of person, please print)
(phone number of person)
relationship
Signature:
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Date
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MM slash DD slash YYYY
By HIPAA standards, we are not allowed to leave results of your lab tests, x-rays, diagnostics, medications, etc., related to your specific health condition on your voicemail, answering machine, fax, etc. However, if you feel that your message retrieval system is safe and your information is protected, you must give us your written consent to allow us to leave your information on your messaging systems. Please choose one of the options below. Note: if you would like to revoke your option at any time, we will need your written notification.
(Initials)
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Appointment reminders and any information regarding your treatment may be called to (check below):
my home phone #/voicemail
my cell phone/voicemail
my office phone/voicemail
other, please indicate
(Initials)
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I have a copy of the "Notice of Privacy Practices" and have reviewed it.
Patient's printed name
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Patient's signature
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Date
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MM slash DD slash YYYY
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I accept the
Terms of Use
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