PATIENT HIPAA CONSENT FORM
Premier Podiatry LLC
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out: • Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment); • Obtaining payment from third party payers (e.g. my insurance company); • The day-to-day healthcare operations of your practice. I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
I authorize the release of information including the diagnosis, records; examination rendered to me and claims information.
This information may be released to: 1. ___________________________________________Relationship to pt:_____________________
2. ___________________________________________Relationship to pt: ______________________
3. ___________________________________________Relationship to pt:______________________
Information is not to be released to anyone unless they are listed on this consent. The release of this information will remain in effect until terminated by me in writing
Patient Name/ DOB _________________________________________________________ Signature___________________________________________________________________
Relationship to Patient ______________________________________________________ Today’s Date________________________________________________________________