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Hipaa Form

Carefree Internal Medicine

Seema Mohan, M.D. & Diana Hrdina, M.D.

HIPAA Form

Printed Name

HIPAA – Health Insurance Portability and Accountability Act, a 1996 Federal law that restricts access to individuals’ private medical information or the sharing of medical information without written consent of the patient.

I hereby give consent to Carefree Internal Medicine to share all medical information with the individual(s) listed below. This will also be used for any prescriptions or information you want picked up.

Name:

Date of Birth:

Relation:

Name:

Date of Birth:

Relation:

Name:

Date of Birth:

Relation:

Patient’s Name:

Date of Birth:

Address:

Phone:

Patients Signature:

Date:

Office Staff Signature:

Date: