PLEASE COPY this “HIPPA and CONFIDENTIALITY FORM” below and PASTE the signed copy and send through this Contact form here or on the CONTACT PAGE (click here). You may also copy and print the form and bring to your first or second session.
HIPAA Compliance Patient Consent Form
This Federal and State compliant HIPPA Form is our Notice of Privacy Practices
This form provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. By your signature you indicate that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.
You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
By signing this form (personal or authorized e-signature), I understand that:
Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
The practice may condition receipt of treatment upon execution of this consent.
If we have your address, phone, email, text information, we will use such to contact you if necessary about appointments, information, exchanges, payments, leave messages etc. without any further consent unless you explain what numbers and contact methods are or are not okay with you in this space:
Your confidentiality and privilege of privacy is very guarded by this practice in compliance with Federal and State laws. This means that we only speak or correspond with individuals about you and/or your treatment if the following occurs:
- If you give permission to communicate with some stated individual/organization by authorized email or paper correspondence.
- If you use insurance and the insurance company requests minimal information to help with your reimbursement.
- If any of the following safety concerns that you describe to us during any communication to us: suicidal plans and intentions, homicidal plans and intentions, child abuse reported (including child porn), elder abuse reported, major property damage planned and intended. In summary, any planned intent to harm self, others, property or any known planned intent to harm others must be reported to help keep safety concerns in check. These situations reported to a therapist are limits to your privacy and confidentiality.
Is there anyone you wish us to contact in order to discuss your situation? Names, phone numbers, addresses are helpful.
This consent and explanation of HIPPA rights and Privacy/Confidentiality Limits and Rights was signed by: ____________________________________________________ (PRINT NAME PLEASE and authorize any e-signatures)
Signature: ________________________________________________________________ Date: _________________ Witness: _________________________________________________________________ Date: _________________
PLEASE COPY the ABOVE “HIPPA and CONFIDENTIALITY FORM” and PASTE the signed copy and send through this Contact form here or on the CONTACT PAGE (click here). You may also copy and print the form and bring to your first or second session.
Contact information too: DrCarolFrancis@gmail.com 310-543-1824