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HIPAA Compliance Patient Consent Form 

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. 

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing  our  consent. 

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. 

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. 

We strive to render excellent care to you and the rest of our patients. Your care and treatment is a priority for us. We also ask that you respect your Clinician Practitioner and expertise as well. In an attempt to be consistent with this, we have a Cancellation Policy that allow us to schedule appointments for our clients, with respect for your time, the next client's time, and our clinician practitioner time. Our policy is as follows: 

We request that you give a notice not later than 48 hours prior your scheduled appointment in the event that you can not make it. If the client misses an appointment without contacting us , it is considered a missed or "No show" appointment. Additionally, if a client is more than 15 minutes late for an appointment, it will be considered as "No Show" appointment, and that appointment will be re-scheduled.  The $30 deposit when booking  your appointment for consultation is non-refundable after 48 hours. For other appointment with full payment, we will deduct $30 from the balance.