Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
HIPAA Consent & Authorization
HIPAA Privacy Acknowledgment Please review and acknowledge our privacy practices related to your health information.
Notice of Privacy Practices In compliance with the Health Insurance Portability and Accountability Act (HIPAA), our practice is committed to protecting your personal health information. We use and disclose your information for treatment, payment, and healthcare operations. Your information will not be shared without your consent unless required by law.
I have read and understand the Notice of Privacy Practices.
I consent to the use and disclosure of my health information for treatment, payment, and healthcare operations.
Full Name *
Date of Birth *
____ / ____ / ________
Today's Date *
____ / ____ / ________
HIPAA Consent & Authorization template from formisoft.com. formisoft.com/intake-templates/hipaa-consent