HIPAA Consent – A Primary Care Clinic for Adults

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Name

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I give A Primary Care Clinic for Adults "APCCFA" my consent to use or disclose my Protected Health Information "PHI" in order to carry out my treatment, obtain payment from my health insurance for services, obtain prior-authorizations for imaging &/or medications, to refer me to another provider & for other health care operations.

I understand that I have the right to review &/or request a copy of APCCFA's Notice of Privacy Practices for a more complete description of uses and disclosures, before signing this consent.

I understand that APCCFA has the right to modify their privacy practices. APCCFA will notify me of any changes and provide an updated copy of their privacy practices upon my request.

I understand that I have the right to request a restriction as to how my PHI is used, to be submitted in writing. I understand that if APCCFA agrees to my requested restrictions they must comply. However, I also understand that APCCFA is not required to agree to said request.

I understand that I may revoke with consent at any time by submitting a written request to APCCFA. I understand that revoking my consent will not apply to any PHI that has already been used or disclosed.

With my e-signature below , I agree to APCCFA's privacy practices.

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