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HIPAA Acknowledgement and Consent Form

HIPAA Acknowledgement and Consent Form

 

 Horizon Oncology Center

1345 Unity Place Suite 345

Lafayette, IN 47905

765-446-5111

HIPAA Acknowledgement and Consent Form

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly.

Obtain payment from designated third-party payers.

Conduct normal health care operations such as quality assessments or evaluations, and physician certifications.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information (available in office in print form or on the office website http://www.horizononcologycenter.com ). I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notices of Privacy Practices.

I understand that I may request in writing that this organization restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand the organization is not required to agree to my requested restrictions, but if the organization does agree, then it is bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that the organization has taken action relying on this consent.

 

____________________________________________                                    _____________________________

Signature of Patient /Patient Representative                                                                 Date

 

 

____________________________________________                                      _____________________________

Name of Patient/ Patient Representative (please print) Relationship to Patient    Date

 

 

COMPANY USE ONLY:

We attempted to obtain written acknowledgement of patients’ receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained from the patient for the following reason: