Hixny Consent Form Agreement for us to access your medical records via the regional health information exchange. Telehealth Consent Form Consent for us to use video and telephone communication means to meet on your health needs. Annual Health Assessment Member questionnaire as a part of a Medicare Annual Wellness or Physical Exam visit. Notice of Charge Letter notification to members of potential charges based on insurance coverage. HIPPA Notice of Privacy Practices Notice of individual privacy rights as per The United States Health Insurance Portability and Accountability Act of 1996 (HIPAA). Consent to Telehealth Agreement for telehealth or video consultations with provider. NIPAA Notice of Privacy Practices PDF Patient Portal Instructions