Healthy Living First Medical Group

Kansas City, KS

HIPAA Privacy Authorization and Consent Form

This form authorizes Healthy Living First Medical Group to use and/or disclose your protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

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1. Patient Identification

Patient First name

Patient Last name

DOB

Month

Day

Year

Phone

2. Authorization for Use and Disclosure

I hereby authorize Healthy Living First Medical Group to use and disclose my protected health information (PHI) as described below for the purposes of treatment, payment, and healthcare operations.

Information to be disclosed may include (check all that apply):

Complete Medical Record (including progress notes, lab results, imaging, and billing)

Only specific treatment notes/dates:

Billing and financial records only

treatment notes/dates

3. Designated Individuals (Family/Friends Sharing)

I authorize Healthy Living First Medical Group to discuss my medical condition, appointments, and billing information with the following individuals (e.g., spouse, children, caretakers):

1. Name

Relationship

Phone

2. Name

Relationship

Phone

4. Communication Preferences

Please indicate how you prefer to be contacted regarding appointments, test results, or billing:

Voicemail

Yes - You may leave a detailed voicemail at my primary number.

Text Message:

Yes - You may send appointment reminders via text.

Yes - You may contact me via the email address on file.

5. Patient Rights and Acknowledgments

Right to Revoke: I understand that I have the right to revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it.
Voluntary Sign-off: I understand that signing this form is voluntary. Healthy Living First Medical Group cannot condition my treatment, payment, or enrollment on whether I sign this authorization.
Redisclosure: I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations.
Expiration: This authorization will remain in effect indefinitely unless a specific expiration date or event is completed here.

Expiration Date

6. Signature and Acknowledgment

By signing below, I acknowledge that I have received, read, and understood Healthy Living First Medical Group’s Notice of Privacy Practices and agree to the terms of this HIPAA authorization.

Patient / Legal Guardian Signature

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Print Name (if Guardian)

Relationship to Patient:

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