You don't want to add this to your intake form..instead it should be added to your consent forms. Also you need to decide which you will be doing .. an "opt in" or "opt out". An Opt in would mean patients have to sign to "opt in", by default they are not added. An "opt OUT" would mean by default everyone is in and patients can choose to "opt out". In addition to federal privacy laws (HIPAA) you will want to research state privacy laws as well which might have added patient protection to it.
Either consent should have following:
explanation of what the health record is
statement of who sees it, where it goes, etc.
statement on how it's protected
How patient can opt in or opt out (depending on the model your practice chooses)
We have some samples, but here is a ROUGH sample of both opt in and opt out for the ending
Opt Out
__ [Practice Name] May not share health information maintained by [Practice Name] or health care orgainization(s) listed below. I understand that all health information maintained by [Practice Name] and/or organization(s) listed below will NOT be a part of my patient health record in [ state ] Health Information exchange. In cases of medical emergency, my doctor may request to view my health records to diagnose or treat my emergency,
Opt In
__ [Practice Name] May share health information maintained by [Practice Name] or health care orgainization(s) with the exception of the following :
[Space provided for patient to specify any exceptions]
There should also be a spot for patient to "rescind" any previous opt in or opt out.
Patient's full legal name, Address, City, State, Zip, DOB, Gender and last 4 of Social Security # should proceed this with signature line for patient or legal representative.
Ending should be concluded with following:
By signing as a legal representative, I am certifying that I am legally authorized to act on behalf of the patient