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New Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment, or
Healthcare Operations.

The Healthcare Insurance Portability and Accountability act of 1996 (“HIPPA”) is a federal program, which requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept confidential. This act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPPA” provides penalties for covered entities that misuse personal health information.

We are required by law to maintain the privacy of your protect health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

As required by “HIPPA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes: treatment, payment, health care operations. • Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. • Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. • Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost management analysis, and customer service. I understand and have been provided, (see brochure at front desk), with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. If I have any further questions in regard to the Privacy Practices I can contact the privacy officer.

I understand that P.E.A.C.H. Rehabilitation and Wellness is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken in reliance thereon.

I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

I further understand that P.E.A.C.H Rehabilitation and Wellness reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should P.E.A.C.H Rehabilitation and Wellness change their notice, they will send a copy of any revised notice to the address I have provided.

I understand that as part of P.E.A.C.H Rehabilitation and Wellness treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including via fax. I fully understand and accept the terms of this consent

Thanks for submitting!

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