Seema Mohan M.D.

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

    HIPAA Form

    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.