HIPPA Form

PATIENT AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION – HEAR HERE AUDIOLOGY

 

I understand that as part of my health care, the practice originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment.

I understand that this information serves as:
 A basis for planning my care and treatment.
 A means of communication among the health professionals who contribute to my care, such as referrals.
 A source of information for applying my diagnosis and treatment information to my bill.
 A means by which a third-party payer can verify that services billed were actually rendered.
 A tool for routine healthcare operations, such as assessing quality and reviewing the competence of staff

We can provide you with a “Notice of Patient Privacy Practices” that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
 The right to restrict or revoke the use or disclosure of my health information for other uses or purposes.
 The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations.

Restrictions:
I request the following restrictions to the use or disclosure of my health information:

____________________________________________________________________________
Please tell us with whom we may discuss your protected health information:
(Example: spouse (name), children (name(s), other relatives (name(s), friends or caregivers (name(s)_____________________________________________________________________

Messages or Appointment Reminders: ____________________________________________________________________________
May we leave a message at your home using doctor’s/practice name: Yes (    ) No (    )
May we leave a message at your work using the doctor’s/practice name Yes (    ) No (    )

I understand that as part of treatment, payment, or healthcare operations, it may become necessary to disclose health information to another entity, i.e., referrals to other healthcare providers. I consent to such disclosure for these uses as permitted by law.
I fully understand and accept/decline (please circle one) the information of this consent.

 

_________________________________________

Patient/Guardian Signature Date

 

_________________________________________

Print name of Person Signing

502 Pasadena Ave. S.

St. Petersburg, FL 33707

Appointment Booking

info@hearherefl.com

727-289-1212

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