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ASC Procedure Instructions & Forms

Endoscopy - HIPAA Consent Form

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting the Ambulatory Surgery Center at Clinical Associates. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice/ASC provided this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The Patient Understands That:

  • Protected health information may be disclosed or used for treatment, payment, or health care operations.
  • The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
  • The Practice reserves the right to restrict the uses of their information but the Practice does not have to agree to the restrictions.
  • The patient may revoke this Consent in writing at any time and all future disclosures will then cease.
  • The Practice may condition receipt of treatment upon execution of this Consent.

The Consent was signed by:



Patient Name:  
Patient Signature:
(name in corresponding box will act as signature)		 Date:
Signature of Representative/Relationship:
(name in corresponding box will act as signature)		 Date:
Witness Signature:
(name in corresponding box will act as signature)		 Date: