Hippa Form
Consent for Purposes of Treatment, Payment and Health Care Operations
I consent to the use and disclosure of my protected health information by Microcurrent Shoes for the purpose of providing supplies to me, obtaining payment for my health care bills or to conduct the health care operations of Microcurrent Shoes.
My Protected health information means health information, including my demographic information collected from me and created or received by my physician, another health care provider, health plan, my employer or a health care clearinghouse. This protected health care information relates to my past, present or future physical health or condition and identifies me, or there is reasonable basis to believe the information may identify me.
I understand that my receiving supplies from Microcurrent Shoes may be conditioned upon my consent as evidence by my signature on this document.
I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out services, payments, or healthcare operations of the company.
Microcurrent Shoes is not required to agree to the restrictions that I may request. However, if Microcurrent Shoes agrees to restrictions that I request, the restrictions are binding on Microcurrent Shoes and Microcurrent Shoes employees.
I have the right to revoke this consent, in writing, at any time, except that Microcurrent Shoes has taken action in reliance on this consent.
I understand I have a right to review Microcurrent Shoes Notice of Privacy Practices prior to signing this document. The Microcurrent Shoes Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosure of my protected health that will occur in my receiving services, payment of my bills or in the performance of health care operations of Microcurrent Shoes. Notice of Privacy Practices also describes my rights and Microcurrent Shoes duties with respect to my protected health information.
Microcurrent Shoes reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail.
_______________________________________
Signature of Patient or Personal Representative
_______________________________________
Name of Patient or Personal Representative
_______________________________________
Date
Print out (CTRL P TO PRINT) and mail or fax form to
Microcurrent Shoes .
2200 N.E.2nd ave
Boca Raton, FL, 33432
Phone: 561-251-0332
FAX: 561-251-0332
