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HIPAA Forms

 Each of the following forms is a required element of physician compliance with HIPAA. They have been developed by the ACOI Clinical Practice Committee through Chairman Lawrence U. Haspel, DO.

  • New Patient Consent to Use and Dislose Information for Treatment, Payment or Healthcare Operation is used to obtain new patient consent to the disclosure of protected information for permitted uses.


  • Notice of Health Information Practices describes for patients the personal information the office collects, how and when it is disclosed and patient rights related to protected health information.


  • Patient Authorization to Use or Disclose Protected Health Information is used to obtain patient authorization to use or disclose protected information for purposes other than treatment, payment, or health care operations.


    • For more information, contact Ms. Susan Karicher at the ACOI office.