To submit this form, you can either fax it to the given clinic number or email it as a scanned document to the address provided. For in-person submission, visit your healthcare provider's location. Additionally, check with your healthcare provider for any specific submission instructions.

The Patient HIPAA Acknowledgment and Consent Form should be updated regularly. Important dates for review are typically every 2 years. Make sure to check for any changes in 2024 and 2025.

The purpose of this form is to ensure patients understand their rights regarding the privacy of their health information. It outlines how personal health information may be used and shared by the provider. This ensures compliance with HIPAA regulations, protecting patient rights.

• 1. Patient Last Name: The last name of the patient.
• 2. Patient First Name: The first name of the patient.
• 3. Date of Birth: The patient’s date of birth.
• 4. Designated Individuals: Names and contact numbers of individuals with whom information can be shared.
• 5. Patient Signature: Signature of the patient to validate the consent.

Failure to submit this form may result in delays in treatment. Medical records and information sharing will not proceed without consent. This could affect coordination of care with other healthcare providers.

• Delayed Treatment: Without this form, necessary treatments might be postponed.
• Limited Access to Medical Records: No sharing of health information can occur.
• Risk of Miscommunication: Providers may not have the patient's complete health history.

• 1. Initial Registration: First-time patients must complete this form for treatment.
• 2. Updating Consent: Used by returning patients to modify who can access their health information.
• 3. Designating Family Members: Essential when patients want family members to discuss medical conditions.