HIPPA Consent Form
I understand that, as part of my healthcare, Dr. Diane Hughes, LCSW, Ph.D. originates and maintains paper and/or electronic records describing my health history, symptoms, diagnosis and test results, treatment, and any plans for future care or treatment. I understand this information serves as:
- A basis for planning my care and treatment,
- A means of communication among the many health professionals who contribute to my care,
- A source of information for applying my diagnosis and information to my bill,
- A means by which a third-party payer can verify that services billed were actually provided, and
- A tool for routine healthcare operations such as assessing and reviewing the competence of healthcare professionals.
- The right to review the notice prior to signing this consent, and
- The right to request restrictions as to how my health information may be used or disclosed to carry out treatement, payment, or health care operations.
I understand that Dr. Diane Hughes, LCSW, Ph.D. is not required to agree to the restrictions requested. I understand that I my revoke this consent in writing, except to the extent that the organization has already taken action in reliance theron. I also understand that by refusing to sign this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.
I understand that as part of this organization’s treatment, payment or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax or email.
I fully understand and accept the terms of this consent.