HIPAA Compliance Form

Please complete this form to acknowledge the HIPAA-related policies.

Terms and Conditions

I authorize the medical center to use and disclose my health information for the purposes of my treatment or operations.

Revocation Rights

I understand that I may revoke this consent at any time by submitting a written request to the medical center. I also understand that any disclosures made prior to my revocation request cannot be undone.

Acknowledgment of HIPAA Notice of Privacy Practices

By signing this form, I acknowledge that I have received, reviewed, and understand the Notice of Privacy Practices.

Name:

Date:

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