CASA PRIVÉE HIPAA Patient Consent Form

Casa Privée adheres strictly to all the tenants of the HIPAA policy. Please read and sign this form.

The HIPAA Privacy Rule establishes national standards to protect individuals’ medical records and other individually identifiable health information (collectively defined as “protected health information”) and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically. The Rule requires appropriate safeguards to protect the privacy of protected health information and sets limits and conditions on the uses and disclosures that may be made of such information without an individual’s authorization. The Rule also gives individuals rights over their protected health information, including rights to examine and obtain a copy of their health records, to direct a covered entity to transmit to a third party an electronic copy of their protected health information in an electronic health record, and to request corrections.

Further information can be obtained at:

 Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

 Changes to this Notice

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.


If you believe your privacy rights have been violated, you may file a complaint with Casa Privee and with the Secretary of the Department of Health and Human Services. You will not be retaliated against for filing a complaint.

A complaint to Casa Privee may be sent to: HIPAA Privacy Officer, Casa Privee,  1395 Brickell Ave Suite 200, Miami, FL 33131, You may also call our compliance and privacy officer at (305) 434-2647 (English). You may also anonymously register a complaint via a website, email or fax:



You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

1. Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

2.     The practice reserves the right to change the privacy policy as allowed by law.

3. The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.

4. The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.

5. The practice may condition receipt of treatment upon execution of this consent. May we phone, email, or send a text to you to confirm appointments?

May we leave a message on your answering machine at home or on your cell phone? May we discuss your medical condition with any member of your family?

If YES, please name the members allowed:

This consent was signed by:                                                                ___________________(PRINT NAME PLEASE) 

Signature:                                                                                                                                     ____________________


Witness:                                                                                             Date: __________________________                               

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