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Shah & Associates Family Practice, PA Shah & Catchings Family 431 Kessler, Dr. Suite 100, Practice 600 New Waverley Place Suite 205 Cary, NC NC27518 27518 Phones: 9194686820 Fax: 9194686484Consent
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Enter the required personal information, such as full name, address, and date of birth, in the designated fields.
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The HIPAA consent form 12-14-2011.doc is required by individuals who are seeking medical treatment or services from a healthcare provider covered by the Health Insurance Portability and Accountability Act (HIPAA). This includes patients, clients, or individuals who want their protected health information (PHI) to be used or disclosed for specific purposes, such as for treatment, payment, or healthcare operations. It is also applicable to individuals participating in medical research studies or those who need their PHI shared with a specific person or organization.
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The HIPAA consent form 12-14-doc is a document that allows healthcare providers to obtain permission from patients to use or disclose their protected health information (PHI) for specific purposes.
Healthcare providers, health plans, and other covered entities that handle protected health information are required to file the HIPAA consent form 12-14-doc.
To fill out the HIPAA consent form 12-14-doc, individuals must provide personal information such as their name, contact details, and specify the information they consent to share along with their signature and date.
The purpose of the HIPAA consent form 12-14-doc is to ensure that patients are informed about how their health information will be used and to obtain their permission before any disclosure occurs.
The HIPAA consent form 12-14-doc must report the patient's name, the specific uses and disclosures of their PHI that they consent to, the name of the entity requesting consent, and the date signed.
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