HIPAA Consent

HIPAA CONSENT FORM

This consent form allows UROLOGICAL CONSULTANTS OF FLORIDA, P.A. to use and disclose information about me protected under the Health Insurance Portability and Accountability Act of 1996. This information may be used or disclosed to carry out treatment, payment or health care operations.

UROLOGICAL CONSULTANTS OF FLORIDA, P.A. has provided me with a Notice of Privacy Practices, which more completely describes such uses and disclosures. It provided this notice prior to my signing this form in accordance with my right to review its practices before signing consent.

I understand that the terms of the Notice of Privacy Practices may change and that I may obtain revised notices by mail or placing the update on our web site.

I understand that I have the right to request, now and in the future, how protected health information is used or disclosed to carry out treatment, payment and health care operations. I understand that UROLOGICAL CONSULTANTS OF FLORIDA, P.A. may refuse me services if I refuse to sign this consent.

I understand that at any time I have the right to revoke this consent provided that I do so in writing, but that the services may still use information to complete any actions that it began prior to revoking consent and which rely on my protected health information.

I understand that UROLOGICAL CONSULTANTS OF FLORIDA, P.A. may refuse me further service if I revoke this consent.