PRIVACY ACKNOWLEDGEMENT FORM

The Department of Health and Human Services has established a “Privacy Rule” to help ensure that personal information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain Health Care Providers to obtain their patient’s consent for use and disclosure of health information about the parents to carry out treatment, payment, Healthcare operation, and peer review of charts.

As our patient, we want you to know that we respect the privacy of your personal medical information and will do all we can to secure and protect your privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your Healthcare information and information about your treatment, payment, or Healthcare operations, in order to provide health care that is in your best interest.

We also want you to know that we support your full access to your personal medical records. We may have to direct treatment relationships with you (such as laboratories that only interact with physicians and not patients) and may have to disclose personal health information for purposes of treatment, payment in healthcare operations. You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or previously signed consent.

If you have any objections to this form, please ask to speak to our HIPAA compliance officer. You have the right to review our privacy notice, to request restriction, and revoke consent in writing after you have reviewed our privacy notice.