Fields in RED are Required
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Name First:
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Name Last:
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:Phone Number:
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Social Security Number:
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License/Certifcate
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License/Certification Number:
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License Exp Date:
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1. The goals of HIPAA are to guarantee health insurance coverage, reduce fraud and abuse,
protect patient information and to establish standards for administrative simplification.
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2. Organizations or entities affected by the HIPAA regulations include, health plans,
healthcare clearinghouses and healthcare providers to name a few.
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3. A violation under civil law can result in a fine of $500.00 per violation and up to $3000.00
per calender year.
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4. Any criminal misuse of information can result in a prison term of 1 to 10 year.
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5. Privacy Regulation is not set up to provide basic rights for patients.
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6. In relation to HIPAA privacy means determining who should have access, what the
patient's rights to confidentiality are, and what inappropriate access to health records means.
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7. HIPAA Privacy regulation does not override laws that provide less stringent protections.
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8. Privacy Regulation provides that personal health information may be disclosed to
business associates only to help them complete their health care functions.
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9. A parent or guardian is not considered a personal representative of her/his minor child and
does not have the right to see the child's personal health information.
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10. Patient privacy may be violated when PHI (Personal Health Information) is left on voice
mail messages or telephone answering machines.
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