Privacy Notice

 ESPRIT HEALING CENTER
1058 LINCOLN AVE. SAN JOSE, CA   
95125 (408)-275-6622
         
HIPPA PRIVACY AUTHORIZATION FOR USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION
This authorization is prepared pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. Section 1320d, et, seq., and regulations promulgated thereunder, as amended from time to time (collectively referred to as “HIPPA”).
This authorization affects your right in the privacy of your personal healthcare information. Please read it carefully before signing.
Esprit Healing Center, will not condition treatment payment, enrollment in a health plan, or eligibility for benefits, as applicable, on your providing authorization for the requested use or disclosure. YOU MAY REFUSE TO SIGN THIS AUTHORIZATION.
By signing this authorization you acknowledge and agree that Esprit Healing Center may use or disclose your medical history for the purpose(s) of further treatment evaluation, referrals to another health care facility or medical practitioner and/or your insurance company.
Further, by signing this authorization you acknowledge that you have been provided a copy of and have read and understand Esprit Healing Center’s HIPPA privacy Notice. If at any time the conditions of this authorization change, you will be notified.
In accordance with your rights you may inspect or copy your personal Health Information in the designated record set maintained by Esprit Healing Center for as long as the PHI is maintained in the designated record set.
You have the right to revoke this authorization, in writing, at any time, except to the extend that Esprit Healing Center has taken action in reliance on it. A revocation is effective upon receipt by Esprit Healing Center of a written request to revoke.
Patient Name: ___________________________________________________________ Patient Signature: _________________________________________________________ Date: _____________________ Witness: ______________________________________ Copy of Consent to Patient: ____________________Yes _______________________No
Rev: 06/11/2008 HIPPA doc