HIPAA Consent Release
Why do we use a HIPAA Consent Release, The Health Insurance Portability and Accountability Act, also known as HIPAA, was created in 1996 by the US Congress to protect the privacy of your health information. The act prohibits your health care providers from releasing your health care information unless you have provided your health care provider with a HIPAA release form.
Unless you have provided a signed release form, your health care providers are prohibited from discussing any aspect of your medical information with anyone who is not directly involved in your care.
You can download the form below and bring it in with you already filled out or you can do it online and have the form submitted to us and a copy emailed to yourself to speed up the process.
Online Form Below
I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have
certain rights to privacy regarding my protected health information. I understand that this information
can and will be used for:
• Conduct, plan and direct my treatment and follow-up among multiple healthcare providers who
may be involved in that treatment directly and indirectly.
• Obtain payment from third party payers.
• Conduct normal healthcare operations, such as quality assessments and physicians
I have been given the right to review such Notice of Privacy Practices prior to signing the consent. I
understand that this organization has the right to change Notice of Privacy Practices from time to time
and that I may contact this organization at any time to obtain a current copy of this Notice of Privacy
I understand that I may request in writing that you restrict how much of my private information is used
or disclosed to carry out treatment, payment or health care operations. I also understand you are not
required yo agree to any requested restriction, but if you do agree then you are bound to abide by
I understand that I may revoke this consent in writing any time, except to the extent that you have
taken action relying on consent.