New Patient HIPPA Form

CONSENT FOR RELEASE OF INFORMATION FOR TREATMENT, PAYMENT AND HEATH CARE OPERATIONS

(HIPPA)


I,_________________________________, hereby authorize Judy Davis MD (referred to herein as “The Practice”) to use and/or disclose my health information which specifically identifies me or which can reasonably be used to identify me to carry out my treatment, payment and health care operations. I understand that while this consent is voluntary, if I refuse to sign this consent, The Practice can refuse to treat me.


I have been informed that The Practice has prepared a notice (“Notice”), which more fully describes the uses, and disclosures that can be made of my individually identifiable health information for treatment, payment and health care operations. I understand that I have the right to review such Notice prior to signing this consent.


I understand that I may revoke this consent at any time by notifying The Practice, in writing, but if I revoke my consent, such revocation will not affect any actions that The Practices took before receiving my revocation.


I understand that The Practice has reserved the right to change his/her privacy practices and that I can obtain such changed notice upon request.


I understand that I have the right to request that The Practice restricts how my individually identifiable health information is used and/or disclosed to carry out treatment, payment or health operations. I understand that The Practice does not

have to agree to such restrictions, but that once such restrictions are agreed to, The Practice must adhere to such restrictions.


___________________________________________

Signature of patient or patient’s representative

(Form MUST be completed before signing.)



______________________________________________

Printed name of patient or patient’s representative

__________________________________________

Relationship to the patient


_________________

Date


Revised 10/16

 
 
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