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Forms / Consent

Simple Form(s) You May Need to Fill Out

HIPAA requires us to collect your consent before we even act on your behalf. 

Please fill out the following: 1) registration & consent form and 2) agreement & payment form. If you are referred by a NGO or non-profit organization, please contact us for the waived fee form. 

Once filled out, please e-mail to:

Other Forms:

Understanding The HIPPA Law 

HIPAA is an acronym for The Health Insurance Portability and Accountability Act and was first enforced in 1996. This Act was created to provide protection for personal health information. This Act is balanced so that it provides needed information to health care providers for patient care, but also provides patients certain rights to that personal information.

Enforcement for most HIPAA covered entities was enforced beginning on April 14, 2003 while smaller health insurers were given one additional year. Enforcement activities include complaint investigation, compliance reviews, and continued education. The enforcement activities resulted in an improvement of privacy protection for the health care information of individuals.

The Privacy Rule is a federal law which allows you certain rights over your personal health information. You may obtain your health records, correct information on your health record and give permission to those who need to see your health records. This law sets rules and limitations on who can view and receive your personal information whether it is verbal, electronic, or written. The information that is protected includes any information that is put in your medical record by doctors, nurses, or other health care providers, any information in your heath insurer's computer system, billing information, and any conversations that are discussed between your doctor and nurses in regards to your treatment or care. The Privacy Rule applies to covered entities only; these include health plans, health care clearinghouses, and health care providers who submit health care information electronically.

The introduction of the HIPAA laws has helped improve the awareness of personal health care information issues. With patients, it has improved the level of comfort and trust that their information is being handled correctly.

If you have any questions, please e-mail to:

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