HIPAA consent form
Consent to Use and
Disclose Your Health Information
This form is an agreement between you, _________________________________________ and
Richard S. Cooper, Ph.D. and Susan D. Griffith, Ph.D. of Chapel Hill/Durham Psychotherapy Associates and Creative Solution Specialists and Alamance Psychotherapy Associates and Creative Solution Specialists. When we use the word "you" below, it will mean your child, relative, or other person if
you have written his or her name here ____________________________________ .
When we examine, diagnose, treat, or refer you we will be collecting what the law calls Protected Health Information (PHI) about you. We need to use this information here to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others who provide treatment to you or need it to arrange payment for your treatment or for other business or government functions.
By signing this form you are agreeing to let us use your information here and send to others. The
Notice of Privacy Practices explains in more detail your rights and how we can use and share your information. Please read this before you sign this Consent form.
If you do not sign this consent form agreeing to what is in our Notice of Privacy Practices
we cannot treat you.
In the future we may change how we use and share your information and so may change our Notice of Privacy Practices. If we do change it, you can get a copy from our website, www.EasyToTalkTo.com, or by calling us at (919) 942-3229.
If you are concerned about some of your information, you have the right to ask us to not use or share some of your information for treatment, payment or administrative purposes. You will have to tell us what you want in writing. Although we will try to respect your wishes, we are not required to agree to these limitations. However, if we do agree, we promise to comply with your wish.
After you have signed this consent, you have the right to revoke it (by writing a letter telling us you no longer consent) and we will comply with your wishes about using or sharing your information from that time on but we may already have used or shared some of your information and cannot change that.
Signature of client or his or her personal representative Date
Printed name of client or personal representative Relationship to the client
Description of personal representative's authority
_________Date NPP copy given to the client/parent/personal representative