HIPAA Patient Consent Form

Gabriel Orverholtzer, DDS.

325 Grove Street Bishop, CA 93514

HIPAA Patient Consent Form

Our notice of  Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing the Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contracting our office.

You have the right to request that we restrict how protected health information about you us used or disclosed for treatment payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996. (HIPPA)

The patient understand that:
. Protected health information may be disclosed or used for treatment, payment, or health care operation.
. The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
. The Practice reserves the right to change the Notice of Privacy Practices.
. The patient has the right to restrict the uses of their information but the Practice does not have to agree to the restrictions.
. The patient may revoke this Consent in writing at any time and all future disclosures will then cease.
. The Practice may condition receipt of treatment upon the execution of this Consent.
Email
The Consent was signed by:
Relationship to Patient (if other than patient)