HIPAA Compliance Patient Consent Form
The terms of the notice may change, if so, you will be notified at your next login or visit to the iTrust.io website to update your acknowledgement and/or electronic consent signature prior to using the website.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations, including its storage, transmission and communication. We are not required to agree with your restriction, but if we do, we shall honor this agreement under those terms. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations including your health care providers use of iTrust.io to store, transmit, or communicate your PHI in various ways using iTrust website services.
By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage for research or publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
By signing this form, I understand that:
➢ Protected health information may be disclosed or used for treatment, payment, or healthcare operations, digital storage communications and/or transmissions.
➢ iTrust.io and covered Health Care Professional have the right to restrict the use of the information, but the iTrust.io does not have to agree to those restrictions.
➢ The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
➢ iTrust.io may condition its website services, storage, communication, and transmission of PHI upon execution of this consent.
iTrust.io may phone, email, or send a text to you to confirm appointments
iTrust.io may leave a messages on your home phone or on your cell phone
iTrust.io may communicate or transmit PHI to, with and for your health care provider for treatment, payment, or operations.
iTrust.io may we discuss your medical condition with any member of your family through iTrust.io website.