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.
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This form was created inside of Kahl Therapy Corner, LLC.