HIPAA Patient Consent
Originally effective: 12/1/2020
Our HIPAA Notice Regarding Privacy of Personal Health Information 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 this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.
You have the right to request that we restrict how protected health information about you is 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 the 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 (HIPAA).
The patient understands that:
- Protected health information may be disclosed or used for treatment, payment, or health care operations.
- The Practice has a HIPAA Notice Regarding Privacy of Personal Health Information and that the patient has the opportunity to review this Notice.
- The Practice reserves the right to change the HIPAA Notice Regarding Privacy of Personal Health Information.
- The patient has the right to restrict the uses of their information, but the Practice does not have to agree to those 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.
- A copy of this notice may be requested in person, by mail, or by phone during normal business hours.
Informed Patient Consent:
- I give my permission to Kaufman Allergy Asthma and Immunology, PLLC to treat me, including any procedures, as deemed necessary in the exercise of their professional judgment.
- I understand medical care requires my cooperation, and I will follow my doctor’s orders and prescription. If indicated, I will make and keep appointments for follow up care and call the office to note any changes or concerns in my condition.
- I authorize my Kaufman Allergy Asthma and Immunology, PLLC to take photographs using a secure platform called Athena Capture to enter photographs into my medical record. Athena Capture immediately erases the photograph from the device used to take the photo and does not store any patient information. I understand the purpose of this use is for documentation for my medical record.
- I authorize my physician to release any information, including the diagnosis and the records of any treatments or examination rendered to me or my child during the period of such medical care, to third party payers including Medicare.
- I authorize and request that my insurance company, in lieu of reimbursing me directly, pay the doctor or medical office any benefits for services rendered.
- I understand that my insurance company carrier may pay less than the actual bill for services; I agree that it is my responsibility to provide for payment of all services rendered on my behalf or my dependents.
- I understand I may be billed by an outside laboratory for work that was performed in the office. If my insurance company does not have a contracted lab or facility, or if my insurance company does not cover the services, Kaufman Allergy Asthma and Immunology, PLLC may bill me.
- I will notify Kaufman Allergy Asthma and Immunology, PLLC if/when there are pertinent changes to my medical history, including medical conditions and changes in insurance carriers. I will also notify the office of any changes in my demographic information.
Patient’s name Date of Birth
Signature of Responsible Party (guarantor) Relationship to Patient