HIPAA Consent Form

This HIPAA Consent Form outlines your rights under the Health Insurance Portability and Accountability Act (HIPAA) and gives Down to Earth Wellness Center permission to use and disclose your health information in accordance with applicable law. Please review this document carefully before signing.

Purpose of Consent:

By signing the Consent & Authorization Summary Signature Page, you authorize Down to Earth Wellness Center to use and disclose your protected health information (PHI) for the purposes of providing treatment, payment, and healthcare operations, as outlined in our Notice of Privacy Practices.

PHI includes information such as your medical history, test results, diagnoses, treatment records, billing information, and other personal health data.

This consent is intended to:

• Allow communication between our staff, healthcare providers, and necessary third parties involved in your care (such as specialists, labs, and pharmacies) • Facilitate billing, payment, and insurance claims processing • Enable routine healthcare operations, including quality assessment and improvement activities, patient outreach, and staff training

Your Rights:

You have the right to:

1. Inspect and Obtain Copies of Your Medical Records: You may request to view and/or receive copies of your health information at any time.
2. Request Restrictions on Use/Disclosure: You may request restrictions on the use or disclosure of your PHI, though we may not be required to agree to such restrictions.
3. Confidential Communication: You may request confidential communications by alternative means (e.g., only contacting you at work or via mail).
4. Revoke Consent: You have the right to revoke this consent at any time in writing, except to the extent that action has already been taken in reliance on it.
5. Receive a Copy of This Consent: You are entitled to a copy of this consent for your records.

Conditions for Consent:

I understand that:

• I have the right to review Down to Earth Wellness Center’s Notice of Privacy Practices, which provides more detailed information about how my PHI may be used and disclosed. • This consent remains in effect until I revoke it in writing. • If I revoke this consent, Down to Earth Wellness Center may be unable to provide certain services or may need to take appropriate actions related to the revocation. • Down to Earth Wellness Center will not condition treatment on whether or not I sign the Consent & Authorization Summary Signature Page, but failure to provide consent may affect services provided by the Center.

Acknowledgment and Signature:

By signing the Consent & Authorization Summary Signature Page, I acknowledge that I have read and understand this consent form. I authorize Down to Earth Wellness Center to use and disclose my protected health information as described above and outlined in the Notice of Privacy Practices.