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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


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




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: