David’s Example Form 1 Name(Required) First Last Consent(Required) I agree to:The "Health Insurance Portability and Accountability Act" of 1996 (HIPAA) is designed to protect the privacy of your medical records, or "Protected Health Information" (PHI). By signing this document you are acknowledging that you have read and understand the privacy policy given to you by PA Thrive Partnership. This authorization will remain in effect until it is revoked in writing. -I understand that my de-identified PHI may be used and disclosed to carry out treatment, payment, or health care operations. -I understand that I have the right to read, review, and be explained to, the privacy practices before signing this consent. -I understand that the terms of this privacy statement may change as described in this notice, and that you have the right to be notified of these changes. -I understand that I have the right to request a restriction on how my PHI is used or disclosed to carry out treatment, payment or health care operations, however a covered entity (PA Thrive Partnership) is not required to agree to restrictions. If PA Thrive Partnership does agree to this request, the request is binding. -I understand that I have the right to revoke the consent in writing except to the extent that PA Thrive Partnership has taken action during the time frame when the release was intact. By signing this document you acknowledge that you have read and understand the privacy policy given to you by the staff at PA Thrive Partnership. This authorization will remain in effect until it is revoked in writing.By checking off the "I accept" box, you agree to this site the use of cookies and data.