HIPPAHealth Insurance Portability and Accountability ActHIPAA provides patients with reassurance that their information is private. Please fill in the fields below and submit. HIPPA HIPPA provides patients with reassurance that their information is private. We give you the right to put restrictions on your personal information. Please answer the following questions to allow us to provide you with the medical confidentiality you want and deserve. 1. I wish to be contacted in the following manner regarding appointment confirmations, insurance problems and/or test results: (please check all that apply) Home Phone Cell Phone Work Phone 2. In regards to the question above, may we leave a message with the above information, either machine or with a person, even if the message may include a diagnosis or other medical information? Yes, a message is fine Yes, please do not leave a diagnosis No, please do not leave a message 3. Please list below any family members or friends who you allow to have certain access to your protected health information. (I.e. calling our office to make and/or confirm an appointment for you, calling for results, picking up a prescription) Name * Relationship * Name * Relationship * Name * Relationship * Patient Name Patient Name First First Last Last Signature Clear reCAPTCHA If you are human, leave this field blank. Submit Δ CompanyAbout UsContactTestimonialsLeave a Review resourcesResearch ChiropracticNeuroFeedbackTrigger PointPhysical therapy formsNew Patient FOrmUpdate Patient InfoHIpaa releaseAssignment & directrelease locationLamboy Family Chiropractic245 Conklin StreeTFarmingdale, NY 11735Main 516.249.4488 Twitter Facebook Mail
