HIPAA Consent Form
Complete all sections to give consent for the use of your Protected Health Information.
Consent for Use
By signing this form, I consent to the following:
Use and Disclosure of Protected Health Information: I authorize the healthcare provider to use and disclose my health information for the purposes of treatment.
Revocation Rights: I understand that I have the right to revoke this consent at any time by providing written notice to my healthcare provider, except where information has already been disclosed.
Acknowledgments
By signing this form, I acknowledge that I have received and reviewed the Notice of Privacy Practices and I understand that this consent will remain in effect until revoked or as required by law.
Name:
Date:
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