HIPAA

Section A: Patient Give Consent

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

Date of Birth

Date

Section B: To the patient- Please read the following statements carefully

Purpose of consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payments activities and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provided a description of our treatment, payment activates, and healthcare operations, of the uses and discosures we may make of your protected copy of our notice accompanies this consent. We encourage you to read it carefully completely before signing this consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our practices we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

Angie Anderson
1720 Destiny Lane, Bowling Green Ky, 42104
Telephone: 270-842-3554 Fax: 270-781-4644
(You are entitled to a copy of this consent after you sign it)

Name

First NameLast Name

have had full opportunity to read and consider the contents of this form and your Notice of Privacy Practices. I understand that, by signing this consent form I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activates and healthcare operations.

Signature

Date

Right to Revoke: You will have the right to revoke this consent at any time by giving us a written notice of your revocation submitted to the contacted person listed above. Please understand that, revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this consent.

Revocation of Consent:

I revoke my consent for your use and disclosure of my protected health information for treatment, pay,emt activates, and healthcare operations.

I Understand that revocation of my consent will not affect any action you took in reliance on my consent before you received this written notice of revocation. I also understand that you may decline to treat or to continue treating me after I have revoked my consent.

Signature

Date