Collins Surgical Associates P.C.

Telephone: (860) 522-1024   Fax (860) 278-4613

PRIVACY RULE (HIPPA)

PATIENT CONSENT FORM

            The Department of Health and Human Services has established a “Privacy Rule” to help insure that personal health care information is protected for privacy.  I understand that I have certain rights to privacy regarding my protected health information.  When it is appropriate and necessary, I understand that the minimum necessary information about treatment, payment or health care operations will be provided in order to provide health care that is in my best interest.

I have been informed by you and/or your representative of 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 review such Notice of Privacy Practices prior to signing this consent.  I may refuse to consent to the use or disclosure of my personal health Information but this must be in writing.  Under this law you have the right to refuse to treat me should I refuse to allow disclosure of my Personal Health Information (PHI),  I understand that I may revoke this consent in writing at any time except to the extent of actions that have already been taken which relied on this or previously signed consent.

 

I _____________________________________ have received/reviewed a copy of this office’s Notice of Privacy Practices.

 

Signature _________________________________________ Date __________________________

SIGNATURE ON FILE

 

I authorize the release of any medical information to my insurance carrier as requested by them. I permit a copy of this authorization to be used in place of the original.

 

Signature ________________________________________Date___________________________