Healthcare HIPAA Certification

HEALTHCARE HIPAA CERTIFICATION

Patient Information

Patient Name:

Date of Birth:     Gender: Male Female Other

Emergency Contact

Insurance Information

Medical History (brief)

HIPAA Certification and Authorization

I certify that I have received a copy of the Notice of Privacy Practices describing how my protected health information (PHI) may be used or disclosed, and my rights under applicable privacy laws. I understand the Notice sets forth:

• Permitted uses and disclosures for treatment, payment and health care operations;
• My right to request restriction of certain uses and disclosures;
• My right to request confidential communications and to inspect or obtain a copy of my PHI;
• How to file a complaint regarding privacy practices without retaliation.

Authorization for Use and Disclosure: I authorize the healthcare providers and staff of this facility and my health insurer (where applicable) to use and disclose my PHI as necessary for treatment, payment, and healthcare operations. I understand certain categories of information (e.g., substance abuse treatment records, psychotherapy notes, HIV/AIDS-related information, genetic testing) require explicit authorization for disclosure; such categories will be disclosed only if I specifically consent below.

Treatment Billing / Payment Insurance Claims Healthcare Operations

Sensitive Records — Explicit Authorization Required

By initialing or checking the boxes below, I expressly authorize disclosure of the following sensitive categories of information to the extent contained in my records:

Substance abuse diagnosis/treatment records
Mental health / psychotherapy notes
HIV/AIDS-related information
Genetic testing results

This authorization expires on:    or upon the following event:

Revocation & Rights

I understand that I may revoke this authorization at any time by delivering a written revocation to the facility's Privacy Officer, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures made in reliance on this authorization prior to receipt of the revocation. I understand that treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization unless allowed under law.

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations. I understand that unauthorized use or disclosure of my PHI may result in civil or criminal penalties under applicable law.

I acknowledge that I have received and been offered a copy of the Notice of Privacy Practices.

Certification: By signing below I certify under penalty of law that the information I have provided on this form is true and correct, I have read and understand this HIPAA Certification and Authorization, and I authorize the uses and disclosures described above.

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