HIPAA Form

This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.

Purpose & Duration of Disclosure:
This authorization is for the purpose of allowing my physician to obtain comprehensive medical information necessary for treatment, diagnosis, and continuity of care. This authorization shall remain valid unless revoked in writing by me as described above.

Authorization & Consent:
I hereby authorize DR. BASHAR HMOUD / ADVANCED DIGESTIVE CARE, located at 6255 Inkster Road, Suite 104, Garden City, MI 48135, to obtain and review my medical records at any time from any Electronic Medical Record (EMR) system. This is including, but not limited to, hospital systems such as Garden City Hospital, Trinity Health, Corewell Health, and any other healthcare providers where I have received treatment or services.

I understand that copies of my medical records with Dr. Bashar Hmoud will be shared with my Primary Care Physician for continuity of care purposes.

I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.

I understand that uses and disclosures already made based upon my original permission cannot be taken back and that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards. I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization.

I may request a copy of this authorization after I have signed it and understand that a copy will remain in my chart. A copy of this authorization is as valid as the original.

By providing your cell number, you consent to receive SMS text messages from Dr. Bashar Hmoud's office for appointment reminders and healthcare-related notifications. You will typically receive up to 3 messages per week regarding your appointments. Standard message and data rates may apply. You can opt-out at any time by replying "STOP".

Scope of Information Authorized:
This authorization includes, but is not limited to, access to the following types of information: - Medical history
- Lab results
- Diagnostic reports
- Physician notes
- Medication records
- Immunization records
- Allergies and adverse reactions

Rights of the Patient:
I understand that:
- I have the right to revoke this authorization at any time by providing a written notice to my physician’s office.
- Revocation of this authorization will not affect any actions taken prior to receiving my written revocation.
- Information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.
Updated September 2024