HIPAA Client Contact, Privacy and Consent Form

Note: Please be advised that any examination or representation made by a registered hearing aid dealer and fitter in connection with the practice of fitting and selling of hearing aids, is not an examination, diagnosis or prescription by a person licensed to practice medicine in this Commonwealth and therefore must not be regarded as medical opinion. If you feel that your rights are violated you may contact the State Bureau of Consumer Protection, the Pennsylvania Department of Health in Harrisburg, or your local district attorney. America Hears is required to obtain, and evaluate all of this information prior to the sale of a hearing aid. If you have any questions please call a customer service representative for clarification. All fields must be completed:
	First Name
	Last Name
	Street Address
	City
	State
	ZIP Code
	Phone Number (format = 555-555-5555)
	Email Address
	Date of Birth (format = MM/DD/YYYY)
NOTICE OF PRIVACY PRACTICES As required by federal laws: This notice describes how health information about you (as a client of this company) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review our Notice of Privacy Practices by clicking here.
CLIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION AND CLIENT RIGHTS I hereby give my consent for this company to use and disclose protected hearing health related information (PHI) about me to carry out treatment, payment and hearing healthcare operations (TPO). (The Notice of Privacy Practices provides a more complete description of such uses and disclosures.) I have the right to review the Notice of Privacy Practices prior to signing this consent. This company reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the Privacy Official at 806 Beaver Street Bristol, PA 19007. With this consent, this company may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my hearing healthcare. With this consent, this company may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and client statements. With this consent, this company may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and client statements. I have the right to request that this company restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to this company’s use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, This company may decline to do business with me. Under HIPAA, an individual has the following rights with regard to his/her personal health information (PHI): • The right to receive a copy of the practice’s Notice of Privacy Practices. • The right to request restrictions on certain uses and disclosures of PHI. • The right to request restrictions on how the practice communicates PHI to the patient. • The right to inspect and copy PHI. • The right to request an amendment of PHI. • The right to an accounting of the disclosures of PHI made by the covered entity for purposes other than TPO and not pursuant to a valid authorization. • The right to complain about alleged violations to the practice and DHHS. By confirming your name and clicking "I AGREE," you agree that you have read and understand all of the information, terms and conditions set forth above. I AGREE

HIPAA Client Contact, Privacy and Consent Form

For expert advice call

800-492-4515