HIPAA Privacy

M. Azhar Ali, MD FACS
Âmae Plastic & Reconstructive Surgery
Consent Form

Printable version of the form is also available: HIPAA Privacy Form (PDF)

I consent to the use or disclosure of my protected health information (PHI) by M. Azhar Ali, M.D. for the purpose of providing treatment to me, obtaining payment and for health care operations.

I understand that I have the right to request a restriction as to how my protected health information is disclosed to carry out treatment, payment or healthcare operations of the practice. M. Azhar Ali, M.D. is not required to agree to the restrictions that I may request. However if Dr. Ali agrees to a restriction that I request, the restriction is binding.

I have the right to revoke this consent, in writing, at any time except to the extent that Dr. Ali has taken action in reliance on this consent.

My “protected health information” means health information, including my demographic information collected from me and created or received by my physician from another health care provider, or my employer or health care clearing house. This protected health information relates to my present or future physical or mental health or condition and identifies me, or there is a reasonable chance the information may identify me.

I understand I have a right to review Dr. Ali’s Notice of Privacy practices. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur during my treatment, payment of my bills or in healthcare operations of Dr. Ali’s practice. The full Notice of Privacy Practices can be obtained by requesting a copy at the front desk.

The Privacy Practices also describes my rights and Dr. Ali’s responsibility to protect my Personal Health information. Dr. Ali reserves the right to revise or amend the Notice of Privacy Practices. Any revision or amendment will be effective for all records, past, present and future. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy or by asking for one at the time of my next appointment.

Thank you for choosing Âmae Plastic Surgery for your procedure. In an effort to provide the very best care to our patients and their families, we would appreciate it if you would spend a few minutes of your time completing this form. Thank you again for your comments.