Free HIPAA Consent Form Template

HIPAA Consent Form

Complete all sections to give consent for the use of your Protected Health Information.

Date

    Name

      Phone Number

        Consent for Use

        By signing this form, I consent to the following:

        1. Use and Disclosure of Protected Health Information: I authorize the healthcare provider to use and disclose my health information for the purposes of treatment.

        2. Revocation Rights: I understand that I have the right to revoke this consent at any time by providing written notice to my healthcare provider, except where information has already been disclosed.

        Acknowledgments

        By signing this form, I acknowledge that I have received and reviewed the Notice of Privacy Practices and I understand that this consent will remain in effect until revoked or as required by law.

        Name:

        Date:

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