This page is essentially a copy of our HIPPA privacy form for new patients. Please read this carefully so that you understand your rights as our patient.

Consent To Use And/Or Disclose Health Information

As part of the new Health Insurance Privacy and Portability Act, we are informing all patients of the appropriate use and disclosure of their protected health information. By signing this form, you are granting consent to Diles Hearing Center to use and disclose your protected health information for the purposes of treatment, payment, and health care operations. Our Notice of Privacy Practices provides more detailed information about how we may use and disclose this protected health information. You have a legal right to review our Notice of Privacy Practices before you sign this consent, and we encourage you to read it in full.

Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting us at (740) 594-3571. You have a right to request that we restrict how we use and disclose your protected health information for the purposes of treatment, payment, or health care operations. We are not required by law to grant your request. However, if we do decide to grant your request, we are bound by our agreement.

You have the right to revoke this consent in writing, except to the extent we already have used or disclosed your protected health information in reliance on your consent.

The HIPPA Privacy permits health care providers to communicate with patients regarding their health care. This includes communicating with patients at their homes, through the mail or by phone, or in some other manner. In addition, the Rule does not prohibit Diles Hearing Center from leaving messages for patients on their answering machines. We also may leave a message with a family member or other person who answers the phone when the patient is not home. However, to reasonably safeguard the individual's privacy, we will take care to limit the amount of information disclosed via phone.

In addition, I may be contacted in the following manner(s) (check all that apply - leave blank if you don't want to be contacted via any of these additional routes).

Work Telephone
___ O.K. to leave message with details
___ Leave message with call-back number only

Written Communication
___ O.K. to mail to my work/office address
___ O.K. to fax to this number___________________

Other________________________________________