Hipaa Form

CAREFREE INTERNAL MEDICINE, PC

Seema Mohan M.D.

PO BOX 5848
CAREFREE, AZ 85377
P: (480) 595-0431 F: (480) 595-2322
www.carefreeinternalmedicine.com

Printed Name

HIPAA – Health Insurance Portability and Accountability Act, a 1996 Federal law that restricts access to individuals’ private medical information or the sharing of medical information without written consent of the patient. For a copy of the HIPAA Policy, please request at your appointment.

I hereby give consent to Carefree Internal Medicine to share all medical information with the individual(s) listed below. This will also be used for any prescriptions or information you want picked up.

Name	Date of Birth	Relation	Phone Number
Name	Date of Birth	Relation	Phone Number
Name	Date of Birth	Relation	Phone Number
Patient’s Name	Date of Birth	Address	Phone
Patient Signature	Date