HIPAA Compliance Patient Consent Form
Our Notice of Privacy Practices 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. You ascertain that agreeing to check the box 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 virtual visit. 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. By checking the box, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
By checking this box, you understand that:
· Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
· JOGO Health Inc. has the right to restrict the use of the information but 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.
· JOGO Health Inc. may condition receipt of treatment upon execution of this consent.