HIPAA Form

HIPAA

474 Hurffville-Crosskeys Road
Atrium One, Suite A - Sewell, NJ 08080
856-582-1000

HIPAA OMNIBUS RULE - Patient acknowledgement of Receipt of Notice of Privacy Practices and Consent/limited authorization & release form. You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.

Date:

The undersigned acknowledges having had full opportunity to read and consider the contents of this HIPAA Consent form and the Notice of Privacy Practices. The undersigned understands that, by signing this consent form, they are giving consent to use and disclose their protected health information to carry out treatment, payment activities, insurance and any other office procedures. A copy of this signed and dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTORS/FACILITIES IN THE FUTURE.

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide this information with your knowledge and consent.

Please print patient's name

Patient Signature (if 18 or older)

Parent / Guardian / Legal Representative Signature

Description of Authority

How do you want to be addressed when summoned from the reception area? First Name Only Proper Sir Name Other

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:

(This includes step-parents, grandparents, and/or any caretakers who can have access to this patient's records):

Name:

Relationship:

Name:

Relationship:

I AUTHORIZE Contact from this office to confirm my appointments, treatment, and billing information via:

Cell Phone Home Phone Work Phone Text Message My Cell Phone Email Confirmation Any of the Above

I AUTHORIZE Contact from this office to information about my health via:

Cell Phone Home Phone Work Phone Text Message My Cell Phone Email Confirmation Any of the Above

I AUTHORIZE Contact from this office to special services, events, fund raising efforts, or new health info via:

Cell Phone Home Phone Work Phone Text Message My Cell Phone Email Confirmation Any of the Above

Your comments regarding Acknowledgement or Consents

Office Use Only As privacy officer, I attempted to obtain the pateint's (or representative's) signature on this Acknowledgement, but did not because:

It was an emergency treatment

The patient refused to sign

I could not communicate with the patient

The patient was unable to sign because:

Other