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. 

I understand and have been provided with a HIPPA Notice of Privacy Policy (click to download) that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges: 

  • 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 furthermore understand that Dr. Diane Hughes, LCSW, Ph.D. reserves the right to change their notice and practices in accordance with section 164.520 of the Code of Federal Regulations. We will provide you with a copy of the most recent version of the Privacy Policy at any time upon written request to Dr. Diane Hughes, LCSW, Ph.D. 2801 Buford Hw, NE, Suite 503, Atlanta, Georgia 30329, or at your next visit.

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.