BONNIE J. BALDWIN, M.D.

Consultants in Plastic Surgery, P. A.

AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY

HIPAA Form

Consent for Use and Disclosure of Health Information

for Treatment, Payment, Healthcare Operations

Name:

Birth date:

Social Security:

I understand that as a part of my healthcare, this organization originates and maintains

health records describing my health history, symptoms, examination and test results,

diagnoses, treatment and any plans for future care of treatment.

I understand that this information serves as:

•

A basis for planning my care and treatment

•

A means of communication among the many healthcare professionals who

contribute to my care

•

A source of information for applying my diagnosis and surgical information to

my bill

•

A means by which a third-party payer can verify that services billed were

actually provided

•

A tool for routine healthcare operations such as assessing care quality and

reviewing the competence of healthcare professionals

I understand I have the right to:

•

Object to the use of my health information for directory purposes

•

Request restrictions as to how my health information may be used or disclosed to

carry out treatment, payment or healthcare operations, and that the organization

is not required to agree to the restrictions requested

•

Revoke this consent in writing, except to the extent that the organization has

already taken action in reliance thereon.

______

I have received a copy of this office’s Notice of Privacy Practices

.

(initial)

I request the following restrictions to the use or disclosure of my

(initial)

health information:

Patient/Legal Representative signature

Date

Witness

*********************************OFFICE USE ONLY**********************************

Accepted

Denied

Signature

Title

Date