HIPAA Acknowledgment and Consent Form

For Hawaiian Hills, a 501(c)(3) Non-Profit Organization

Purpose:

To ensure that you, as a client of Hawaiian Hills, are informed about your rights under the Health Insurance Portability and Accountability Act (HIPAA) and understand how your health information will be protected, used, and disclosed.

Acknowledgment of Receipt of HIPAA Notice of Privacy Practices:

I acknowledge that I have received and read Hawaiian Hills' Notice of Privacy Practices. This notice describes how my health information may be used and disclosed, and how I can access this information.

Client Rights Under HIPAA:

  • Right to Access: I understand that I have the right to access my health information held by Hawaiian Hills.
  • Right to Request Amendments: I can request amendments to my health records if I believe there is an error.
  • Right to Confidential Communications: I can request that Hawaiian Hills communicates with me in a certain way or at a certain location to ensure my privacy.
  • Right to Request Restrictions: I can request restrictions on how my health information is used or disclosed, though Hawaiian Hills is not required to agree to these restrictions.
  • Right to File a Complaint: I understand that I can file a complaint if I believe my privacy rights have been violated.

Use and Disclosure of Health Information:

Hawaiian Hills may use and disclose my health information for the following purposes:

  • Treatment: To provide and coordinate my healthcare.
  • Payment: To obtain payment for my healthcare services.
  • Healthcare Operations: To conduct business operations such as quality assessment and improvement activities.

Authorization for Use of Health Information:

I authorize Hawaiian Hills to use and disclose my health information as described in the Notice of Privacy Practices. I understand that I can revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it.

Confidentiality Commitment:

Hawaiian Hills is committed to protecting the privacy and security of my health information. Measures are in place to safeguard my information against unauthorized access or disclosure.

Acknowledgment and Consent:

By checking the box, I acknowledge that I have read and understood this HIPAA Acknowledgment and Consent Form. I confirm that I have received the Notice of Privacy Practices, and I consent to the use and disclosure of my health information as described.