HIPPA Form

  • With my consent, Plastic Surgeons of the Hudson Valley may use and disclose protected health information about me to carry out treatment, payment and healthcare operations. Please refer to the Notice of Privacy Practices for a more complete description of such uses and disclosures.

    I have the right to review the Notice of Privacy Practices prior to signing this consent.

    Plastic Surgeons of the Hudson Valley has the right to revise its notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Plastic Surgeons of the Hudson Valley, 207 Washington Street, Suite 203, Poughkeepsie, NY 12601.

    With my consent, Plastic Surgeons of the Hudson Valley may call my home, cellular phone or other designated location and leave a message in reference to any items that assist the practice in carrying out treatment, payment and healthcare operations, such as appointment reminders, insurance items and any call pertaining to my clinical care, surgery times and laboratory results among others.

  • With my consent, Plastic Surgeons of the Hudson Valley may mail to my home or other designated location any items that assist the practice in carrying out treatment, payment and healthcare operations, such as appointment reminder cards and patient statements.

    With my consent, Plastic Surgeons of the Hudson Valley may mail me new information they may want to provide. I have the right to request that Plastic Surgeons of the Hudson Valley restrict how it uses or discloses my protected health information to carry out treatment, payment and healthcare operations. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

    By signing this form I am consenting to Plastic Surgeons of the Hudson Valley’s use and disclosure of my private health information to carry out treatment, payment and healthcare operations.

    I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Plastic Surgeons of the Hudson Valley may decline to provide treatment to me.