Patient HIPAA Consent Form
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. PLEASE REVIEW IT CAREFULLY

I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my health information. I understand that this infromation can and will be used to:

1. Conduct, plan and direct my evaluation and trerment among the healthcare providers who may be involved in that treatment.
2. Obtain payment from third-party payers.
3. Conduct normal healthcare operations such as quality assessments and healcare providers certifications.

I have been informed by you of your Notice of Privacy Practices containg a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that Kahl Therapy Corner has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Privacy Practicies.

I understand that I may request in writing that you restirct how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

I undertand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.
Sign in to Google to save your progress. Learn more
Patient Name:
Signature:
Relationship to Patient:
Date:
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Kahl Therapy Corner, LLC. Report Abuse