HIPAA

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

HIPAA

Health Insurance Portability and Accountability Act

The HIPAA privacy rule was created to give individuals the right to restrict the release of their medical information and designate to whom their information may be given. Along these lines, the patient may request confidential communication on PHI (protected health information) and/or designate where this information should be sent, such as home or office. It is okay to contact me in the following manner: *

Cell Phone number

Home Phone number

Work phone number

Required

If we leave a voicemail on your preferred phone number, would you prefer : *

Detailed information, such as appointment time or date, specific questions, results, etc.

A quick message with the call back number

Is it okay if we mail PHI and financial information to your home address and/or your email address? *

Yes

Who, if anyone, would you like to have access to your PHI, including the ability to make appointments or payments? (Please list names) *

Is it okay if we mail or email x-rays to insurance companies or offices that we are referring to? *

Yes

If this information changes, it is your responsibility to inform our practice of those changes. This authorization does not apply to general appointment reminder phone calls nor does it override Kentucky State Laws regarding disclosure of medical information concerning minors. (Please initial and type your full name and Date Of Birth.) *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms