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Carr Dermatology

Patient Consent Form


  Last name

  Mid name

  First name
Birthday:
If Patient is Under Age 18:
Guardian's Name:
Relationship:
* I understand that under the health insurance portability and accountability act of 1996 (HIPAA), I have certain right to privacy regarding my protected health information. I understand that the information can and will be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
- Obtain payment from third-party payers.
- Conduct normal healthcare operations such as quality assessments and physician certificates.
* I have been informed by you of your Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.
* I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
* I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.
*Signature:
Date:
(Your digital signature (full name) is as legally binding as a physical signature.)