{"rest":"https://formdr.com/wp-json/fdpf/v1/","assets":"https://formdr.com/wp-content/plugins/formdr-pdf-to-form/assets/","ctaLabel":"Get a demo with your form","ctaUrl":"https://formdr.com/get-your-form/","preview":{"name":"New Patient HIPAA Consent","outline":{"formName":"New Patient HIPAA Consent","pages":[{"title":"Patient Information","items":[{"id":"f1","parentId":null,"showWhenOption":null,"kind":"name","label":"Patient Name","key":null,"required":true,"options":[],"inputs":[],"html":null,"columns":null},{"id":"f2","parentId":null,"showWhenOption":null,"kind":"date","label":"Date of Birth","key":"birthday","required":true,"options":[],"inputs":[],"html":null,"columns":null},{"id":"f3","parentId":null,"showWhenOption":null,"kind":"radio","label":"Is the patient a minor (under 18)?","key":"isMinor","required":true,"options":["Yes","No"],"inputs":[],"html":null,"columns":null},{"id":"f4","parentId":"f3","showWhenOption":"Yes","kind":"name","label":"Parent/Guardian Name","key":null,"required":true,"options":[],"inputs":[],"html":null,"columns":null}]},{"title":"HIPAA Privacy Notice & Consent","items":[{"id":"f5","parentId":null,"showWhenOption":null,"kind":"paragraph","label":"","key":null,"required":false,"options":[],"inputs":[],"html":"

Notice of Privacy Practices

We are required by law to maintain the privacy of your health information and to provide you with notice of our privacy practices. Your health information may be used and disclosed by our office and other health care providers involved in your care for purposes of treatment, payment, and health care operations.

We may also disclose health information when required by law, in response to court orders or lawful requests from public health authorities, and in other limited circumstances permitted by law. We do not use or disclose health information for any purpose not described in this notice without your written authorization.

You have the right to request access to your health records, request corrections to your health information, request an accounting of disclosures, and request restrictions on the use and disclosure of your health information.

","columns":null},{"id":"f6","parentId":null,"showWhenOption":null,"kind":"checkbox","label":"I acknowledge that I have received and reviewed the Notice of Privacy Practices.","key":"acknowledgedPrivacyNotice","required":true,"options":[],"inputs":[],"html":null,"columns":null}]},{"title":"Consent to Treat","items":[{"id":"f7","parentId":null,"showWhenOption":null,"kind":"paragraph","label":"","key":null,"required":false,"options":[],"inputs":[],"html":"

Consent to Treatment

I, [firstName] [lastName], consent to examination and treatment by the healthcare providers at this practice. I understand that I have the right to refuse any treatment. I authorize this practice to perform necessary diagnostic and treatment procedures and to use my health information for treatment, payment, and health care operations. I also authorize this practice to contact me at the phone number and address provided to discuss my care or to remind me of appointments.

","columns":null},{"id":"f8","parentId":null,"showWhenOption":null,"kind":"signature","label":"Patient Signature","key":"patientSignature","required":true,"options":[],"inputs":[],"html":null,"columns":null},{"id":"f9","parentId":null,"showWhenOption":null,"kind":"signatureDate","label":"Date","key":"signedDate","required":true,"options":[],"inputs":[],"html":null,"columns":null}]},{"title":"Parental/Guardian Consent (if applicable)","items":[{"id":"f10","parentId":null,"showWhenOption":null,"kind":"paragraph","label":"","key":null,"required":false,"options":[],"inputs":[],"html":"

Parental/Guardian Consent for Minor Patient

I, [firstName] [lastName], am the parent or legal guardian of the above-named minor patient. I have read and understand the Notice of Privacy Practices and Consent to Treatment forms. I consent to the examination and treatment of the minor patient by the healthcare providers at this practice and authorize the use and disclosure of the minor patient's health information as described in the Notice of Privacy Practices. I understand that I may be contacted at the phone number and address provided regarding the minor patient's care or appointments.

","columns":null},{"id":"f11","parentId":null,"showWhenOption":null,"kind":"radio","label":"A parent or guardian signature is needed for this patient.","key":"parentSignatureRequired","required":true,"options":["Yes, I am the parent/guardian and sign below","No, this is not a minor or parent is not available"],"inputs":[],"html":null,"columns":null},{"id":"f12","parentId":"f11","showWhenOption":"Yes, I am the parent/guardian and sign below","kind":"signature","label":"Parent/Guardian Signature","key":"parentGuardianSignature","required":true,"options":[],"inputs":[],"html":null,"columns":null},{"id":"f13","parentId":"f11","showWhenOption":"Yes, I am the parent/guardian and sign below","kind":"signatureDate","label":"Date","key":"parentSignedDate","required":true,"options":[],"inputs":[],"html":null,"columns":null}]}],"notes":["This form assumes adult patients may also complete it without a parent/guardian, and minors always require parental/guardian consent. The practice should customize the practice name, contact methods, and any state-specific privacy requirements in the Notice of Privacy Practices paragraph.","The 'parentSignatureRequired' radio is placed at the end so that the patient section is complete first; practices can adjust the flow based on workflow (e.g., ask about minor status upfront and skip adult signature if a parent is signing).","If the practice handles both adult and minor patients in one form, the conditional logic ensures parent/guardian fields only appear for minors, but practices may prefer separate forms or a more prominent upfront question about age.","HIPAA requirements and state privacy laws vary; practices should have legal counsel review this template to ensure compliance with applicable regulations."]}}}