HIPPA Please fill-out the form to the best of your ability and then “submit.” ***We will review all the information at your visit.*** HIPPA Form Full Name Patient Acknowledgment – The above referenced patient hereby states that by signing this Consent they acknowledge and agree as follows (CHECK EACH BOX TO CONSENT).): 1. The Practice’s Privacy Notice has been provided to me prior to my signing the Consent. The Privacy Notice includes a complete description of the uses and/or disclosures of my protected health information (“PHI”) necessary for the Practice to provide treatment to me, and also necessary for the Practice to obtain payment for that treatment and to carry out its health care operations. The Practice explained to me that the Privacy Notice would be available to me in the future at my request. The Practice has further explained my right to obtain a copy of the Privacy Notice prior to signing this Consent, and has encouraged me to read the Privacy Notice carefully prior to my signing this Consent. 2. The Practice reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with applicable law. 3. The Practice’s “Notice of Privacy Practices” is also provided in the lobby and on the Practice’s website at http://www.hpc-stl.com. I may also request a copy from this office at any time via US Mail. 4. This Notice of Privacy Practices also describes my rights and the duties of this office with respect to my protected health information I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way that I can understand. (Type in Full Name Below) Signature (Leave Blank) Date If you are human, leave this field blank. Submit Δ Share this:TwitterFacebookLike this:Like Loading...
