HIPPA Form

Patient’s Name:
Social Security #

LEGAL RESPONSIBILITY

 If you are 18 years old or older, you are legally responsible for yourself, check this box .
 If you are an emancipated child or teenager, and your parents no longer have custody over you please check this box.
 If you are a child or teenager and your parents are divorced please check this box.

Below please list the name of the parents or guardian who has custody over you.

parents or guardian:

USE AND /OR DISCLOSURE

A. I understand that under HIPAA regulations, my health information will be used and disclosed to any health care provider who is involved with my medical treatment of services, my health insurance plan, and any medical billing cleaning house who is involved with your insurance claims fulfillment.
B. Under these new regulations the following people must be authorized by you to have access to your health information your spouse, other family members, and friends; nurse or home aid; legal guardian or other person/organization who is not involved with your medical treatment, insurance plan, or
payment.

Below please list the people/organizations that you authorize to have access to your information.

Name
Phone
Address:
Relationship to Patient :
What Specific Information to Disclose
What date will the disclose expire

CHANGING YOUR MIND: I understand that I may revoke this authorization at any time by giving written notice to your Privacy Officer.

METHOD OF CONTACT

I authorize the office of Carlisle Chiropractic Clinic to contact me the following manner:
 Home Telephone
 Written Mail
 OK to leave message with detailed information
 OK to call my work
 OK to email me
 Leave message with a call back number only

STATEMENT OF UNDERSTANDING

I have reviewed and I understand this Authorization. I also understand that my health information will be used or disclosed to certain business associates of Carlisle Chiropractic Clinic who are part of the healthcare process. These business associates will also keep your health information confidential.
By (Patient)
Date
Or By Patient’s Representative
Date