HIPAA Consent form
Consent For Release Of Information For Treatment, Payment, and Healthcare Operations
The Health Insurance Portability and Accountability Act (HIPAA) requires that Women OB-Gyn
Associates P.C: make available to you a description of how medical information about you may
be used or disclosed and how you can get access to this information. This is called the Notice
of Privacy Practices and copies are available from the receptionists. I acknowledge that a copy
of this notice has been made available to me.
Women OB-Gyn Associates, P.C. is also required to obtain a consent from you to allow us to
communicate with you (or anyone you designate), your insurance and companies, and your
other healthcare providers. I understand that this consent is voluntary and can be revoked (in
writing) at any time. I understand that Women OB-Gyn Associates P.C. can elect not to treat
me if I do not provide this consent or choose to revoke it