HIPAA Patient form

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment, activities and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice o Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions to our Notice, at any time by contacting:

Susan Chilukuri
713-344-0450
privacy@refreshdermatology.com
5427 Bissonnet Street, Houston, TX 77081

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of our revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

I have had full opportunity to read and consider the contents of this Consent form and our Notice Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclose of my protected health information to carry our treatment payment activities, and health care operations.

If this Consent is signed by a personal representative on behalf of the patient, complete the following: