HIPPA Form

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I understand that as part of my healthcare, this organization originate and maintains health records describing my health history, symptoms, examination and test result, diagnoses, treatment and plans for further care or treatment, give my authorization to my physician/physician's staff to discuss my medical issues concerning me to:
,also give my physician/physician's staff permission to leave a message on my home answering machine or to any person answering my home phone
,also give permission to my physician/physician's staff to contact me at my place of employment. If I am unable to be reached there, I give permission to my physician/physician's staff to leave a message for me to return their call
If there is any medical information I do not want to be discuss or a message to be left on my home or at my place of employment, I will notify my Physician/physician's staff of this in writing. If there is any change in information pertaining to this consent, I will also notify my Physician/physician's staff of this in writing
,also give permission to my physician/physician's staff to fax any information regarding me to another physician's office that may be covering for my physician/physician's staff or a physician I may be referred to be my physician/physician's staff.
I have had the chance to read and thing about the consent of this authorized form and I agree with all statement made in this authorization. I understand that by signing this form, I am confirming mu authorization for use and/or disclosure of the protected health information described in this form with the people and/or organization name in this form.
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I acknowledge receipt of the notice of privacy practice form which detail how protected health information may be used and disclosed, And how I may access that information
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