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Patient Hipaa Consent Form

I understand that as part of my healthcare, this organization originates and maintainshealth records describing my health history, symptoms, examination and test results,diagnoses, treatment, and any plans for future care or treatment. I understand that thisinformation serves as:

  • a basis for planning my care and treatment

  • a means of communication among the many health professionals who contributeto my care

  • a source of information for applying my diagnosis and surgical information to mybill

  • a means by which a third-party payer can verify that services billed were actuallyprovided

  • and a tool for routine healthcare operations such as assessing quality andreviewing the competence of healthcare professionals

I understand and have been provided with a Notice of Information Practices  thatprovides a more complete description of information uses and disclosures. I understandthat I have the right to review the notice prior to signing this consent. I understand thatthe organization reserves the right to change their notice and practices and prior toimplementation will mail a copy of any revised notice to the address I’ve provided. Iunderstand that I have the right to object to the use of my health information for directorypurposes. I understand that I have the right to request restrictions as to how my healthinformation may be used or disclosed to carry out treatment, payment, or healthcareoperations and that the organization is not required to agree to the restrictionsrequested. I understand that I may revoke this consent in writing, except to the extentthat the organization has already take action in reliance thereon.

Thanks for submitting!

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