HIPAA Compliance Patient Consent Form
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.
The notice contains a patient’s rights section describing your rights under the law. You ascertain that by becoming a member that you have reviewed our notice before signing up for a session.
The terms of the notice may change, if so, you will be notified at your next contact to update your signature/date.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.
By participating in therapy, you consent to our use of your protected healthcare information. Your information will not be shared without your written consent. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
By participating in therapy services, I understand that:
ï‚· Protected health information may be disclosed or used for treatment, payment, or healthcare operations. The practice reserves the right to change the privacy policy as allowed by law. The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease. The practice may condition receipt of treatment upon execution of this consent.
When you set up a session a consent form and disclosure statement will be emailed to you. You will be required to review, sign and return these forms in order to receive services.