HIPAA Form - Concordia Mind Health

HIPAA Acknowledgment and Consent to Treatment

HIPAA Acknowledgment

Below is a Notice of Privacy Practices. By signing this form the undersigned acknowledges that they have received a copy of the notice of Privacy Practices for Concordia Mind Health.

HIPAA Form

Communication

Concordia Mind Health may share medical and/or billing formation with the following individuals who are involved with patient's care:

Release to:

Relationship:

Release to:

Relationship:

Further, by providing my wireless/cell phone number to Concordia Mind Health, I hereby grant my consent to communicate on my wireless/cell phone for business purposes, including health care services and/or payment on my account. Further, this will include communication using voice messages and text messages.

I ACCEPT

I DECLINE

AUTHORIZATION FOR TREATMENT

I CONSENT TO TREATMENT FOR MYSELF OR MY FAMILY FROM CONCORDIA MIND HEALTH.

Patients Name:

Name of Representative

Patient's Signature

Clear

Signature of Representative if other than Patient

Clear

Date

Relationship to patient

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