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HIPAA

  • Our notice of privacy practices provides information about how we may use and disclose protected health information. 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 we protect health information about you, how it is used, and 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.
    By signing this form, you consent to our use and disclosure to protect health information about your treatment, payment and health care operations. You have the right to revoke this consent, in writing signed by you. However, such a revocation shall not affect any disclosure we have already made in reliance on your prior consent. The practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
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  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY