This form complies with the Federal Health Insurance Portability and Accountability Act (HIPAA). This is a secure form; the information that you enter here will be seen only by the staff of our practice.
Directions:
fill out all applicable fields and submit the form. We will contact you if there are any concerns or errors with your submissions
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Our practice is dedicated to maintaining the privacy of your individually identifiable health information, including audiograms. In conducting our business, we will create records regarding you and the treatment and services we provide you. We are required by law to maintain the confidentiality of health information that identifies you.
My Protected Health Information (PHI) means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical health or mental health condition and identifies me, or there is a reasonable basis to believe the information may identify me.
I consent to Provider’s use or disclose of my PHI for purposes of delivering relevant product and/or technology marketing communication to me. I acknowledge that Provider may receive financial remuneration from the manufacturer in connection with such communications.
We will use and disclose your protected health information with only the physicians that you list on your intake. We will also use and disclose your protected health information to obtain payment for health care services that we provide you. We have our office policy regarding all the ways that we will keep your information private posted and a copy is in the waiting room.
I hereby acknowledge that Contra Costa Hearing Aid Center is in compliance with The Health Insurance Portability and Accountability Act (HIPAA). I further acknowledge that a copy of the current notice has been posted in the reception area, and that a copy of any amended Notice of Privacy Practices will be available at each appointment.
I would like to receive a copy of any amended Notice of Privacy Practices by e-mail at:
Signature
Date
Name
Phone Number
If not signed by the patient, please indicate the relationship:
Parent or Guardian of minor patient
Guardian or Conservator of an incompetent patient
Patient Information:
Patient Name
Patient Address
Last Updated October 10, 2013