HIPPA Form

Consent for Purposes of Treatment, Payment, and Healthcare Operations I consent to the use or disclosure of my protected health information by Broward Center for Counseling for the purpose of diagnosing and providing treatment to me, obtaining payment for my health care bills, or conducting healthcare operations at Broward Center for Counseling. I understand that diagnosis or treatment may be conditioned upon my consent, as evidenced by my signature on this document. I understand that I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment, or healthcare operations of the practice. If Broward Center for Counseling agrees to a restriction that I request, the restriction is binding on Broward Center for Counseling. I have the right to revoke this consent, in writing, at any time, except to the extent that Broward Center for Counseling has acted in reliance on this consent. My “protected health information” means health information, including my demographic information collected from me and created or received by my therapist, another health care provider, a health plan, my employer, or health care insurance. This protected health information relates to my past, my present, or future physical or mental health condition and identifies me, or there is a reasonable basis to believe the information may identify me. I understand I have a right to review in entirety the Broward Center for Counseling Notice of Privacy Practices and may request complete disclosure of such prior to signing this document. This notice of Privacy describes the uses and disclosures of my protected health information that will occur in my treatment, payment of my bills, or in the performance of healthcare operations of Broward Center for Counseling. This Notice of Privacy Practices describes my rights and the duties of Broward Center for Counseling with respect to my protected health information. Broward Center for Counseling reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent via email, or asking for one at the time of my next appointment.