HIPPA

HIPPA Form

I give permission for Healing Hydration, LLC to use or disclose my health information between clinician performing services, the medical director or office staff to ensure treatment is safe to carry out.

I understand that my health information will be kept private and confidential. Private health information will only be shared amoung Healing Hydration, LLC staff when relating to the safety of a service being provided.  

I understand that Healing Hydration, LLC will not release any health information to anyone unless written consent is given by the patient.

I understand that I have the right, as the patient, to request restrictions to be placed on any protected health information that is used. I, also, understand that Healing Hydration, LLC is not required to agree to any request submitted. 

I understand that I may revoke my consent at any time by making a written request and turning it into Healing Hydration, LLC, except for any information that has already been used or disclosed.