HIPPA Health Care Authorization Form (Privacy Practices)
All information you provide us with is confidential in nature and will only be referenced or shared with you, insurance companies, providers and billing or legal facilities who provide us with a signed request. By signing this form I give permission to Dr. Colby Giles, D.C.’s Office to use all information I provide, as this office deems appropriate.
In addition, by signing below I give this office permission to:
Send me correspondence and provide me with health & other related information. Call and/or leave messages for me on an answering machine and/or voicemail. Provide health care professionals & others with my information when requested. Allow staff and other patients to view my name on the sign in register/sheet. Treat me in a semi-open room where others may see me if passing by in the hall. File a health care provider lien to bind insurance companies to forward payment. Display any testimonials I may write.
Forward to/request my records from providers, attorneys & insurance companies.
I am aware other persons in this office may overhear my protected health information during the course of care. I also understand my information may be overheard by other patient’s at the front desk or in other areas of the office. Should I need to speak with the doctor privately at any time, the doctor will provide a room for these conversations.
By signing this form I am giving Dr. Colby Giles, D.C.’s Office permission to use and disclose my private protected information in accordance with the directives listed above.
Acknowledgement of Receipt of Notice of Privacy Practices
Please feel free to read the binder located in the front reception counter. I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand I have the following rights and privileges:
I have the right to review the notice prior to signing this consent.
I have the right to object to the use of my health information for directory purposes.
I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations.
This authorization shall expire on the following date
No Expiration Date The patient identified below authorizes Dr. Colby Giles, D.C.’s Office to use and disclose protected health information in accordance with all items described.