(949) 481-0118 | 30011 Ivy Glenn Dr. Suite 101 Laguna Niguel, CA. 92677

HIPPA FORM

PLEASE READ AND FILL OUT FORM BELOW

Have you heard of HIPAA?

This is the Health lnsurance Portability & Accountability Act of 1996 that was put in place to protect the confidentiality security of personal health data.

Our office complies with these standards so we would like to know how to relay pertinent health information to you if the doctor cannot get a hold of you directly.

Please check all that apply:

Hippa form

Please leave messages at this number(s)
Is it OK for the doctor to leave a message with lab/test results.
It is OK to fax labs/studies to this fax #
It is OK to give my test results to a family member listed below:
It is OK to give my test results to a family member listed below:
Name
MM slash DD slash YYYY
Max. file size: 100 MB.

OR

PRINT FORM PDF

300| | lvy Glenn Drive Suite 10 | Laguna Niguel CA, 97677 | Phone: 949.481.0118 | Fax: 949.481.1162