HIPAA FORMThe Privacy Rule that is contained in HIPAA established a federal requirement that healthcare providers obtain a patient’s written content before using or disclosing the patient’s personal health information to carry out treatment, payment, or healthcare operations (TPO). This must be obtained before information may be used or disclosed for TPO purposes, except in emergency situations. I understand that by giving consent that I am permitting my personal health information to be disclosed to person who will be involved in my treatment, and it may also be used for payment and operational purposes. I acknowledge that I have been provided with Dr. Julie A. Lorber’s Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand I have the right to review Dr. Julie A. Lorber’s “Notice of Privacy Practices” before I sign this consent. Dr. Julie A. Lorber reserves the right to change the terms of the notice of privacy practices. Changes in the privacy practices will be made available to me. I may request additional restrictions on access to this information for treatment, payment, or healthcare operations purposes. I understand that Dr. Julie A. Lorber is not required to comply with this request but if it does, it is bound by such restrictions.I request the following special restriction(s):I understand that from time-to-time Dr. Julie A. Lorber and her staff may inform me of new drugs, treatments, or other services that may be appropriate for a person in my situation (age, sex, etc.). I consent to the use of my identifiable patient information to notify me of such new drugs, treatments, or other services that may be necessary for the continuity of my care, or which may be of benefit in maintaining or improving my health with the understanding that Dr. Julie A. Lorber will not provide such information to others for marketing, fundraising, or similar purposes from my medical records. I may revoke this consent in writing at any time except to the extent that Dr. Julie A. Lorber has already acted in reliance on this consent. By signing this form, I consent to Dr. Julie A. Lorber’s use and disclosures of my health information for treatment, payment, and healthcare operations. NameDate MM slash DD slash YYYY SignatureNameThis field is for validation purposes and should be left unchanged.
