HIPAA Compliance Please fill out and submit the form below. If you are human, leave this field blank. Name * Email * I acknowledge that I have access to the Notice of Privacy Practice on the Mynd Matters website or on paper if requested, which describes the ways in which the practice may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the Privacy Officer, if I have a question or complaint. I understand that this information may be disclosed electronically by the Mynd Matters Provider and/or the Mynd Matters Provider’s business associates. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice’s Notice of Privacy Practice. I Acknowlege the Notice of Privacy Practices * I Acknowlege Disclosures to Friends and/or Family Members DO YOU WANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM THE PROVIDER MAY DISCUSS YOUR MEDICAL CONDITION? IF YES, WHOM? I give permission for my Protected Health Information to be disclosed for purposes of communicating results, findings and care decisions to the family members and others listed below: Name and Relationship In Person Notify In Person By Phone Notify By Phone Phone Number (If Applicable) Name and Relationship In Person Notify In Person By Phone Notify By Phone Phone Number (If Applicable) Name and Relationship In Person Notify In Person By Phone Notify By Phone Phone Number (If Applicable) Patient/Representative may revoke or modify this specific authorization and that revocation or modification must be in writing. Signature * Draw It Type It Clear
