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Patient HIPAA Consent Form

I understand that under the Health Insurance Portability and 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 to:

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.

  • Obtain payment from third-party payers.

  • Conduct normal medical healthcare operations such as quality assessments and physician certifications.

I have been informed by you and your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to reviews such Notice of Privacy Practices prior to signing this consent. I understand that 1800 MCDONOUGH ROAD SURGERY CENTER LLC. has the right to change its Notice of Privacy Practices from time to time and that I may consent them at the above address to obtain a current copy.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

I understand that I may revise this consent in writing at any time, except to the extent that you have taken action relying on this consent.


(No signature of Patient or Parent Representative required at this time)

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