Healthcare HIPAA Policies

HEALTHCARE HIPAA POLICIES

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History (brief)

Notice of Privacy Practices — Summary of Key Policies

This practice is required by federal law to protect the privacy of your health information. Protected Health Information (PHI) may be used or disclosed for treatment, payment, and healthcare operations without your prior written authorization. Examples include: coordination of care with other providers, billing and claims, quality assessment, and utilization review.

We will make reasonable efforts to limit PHI disclosed to the minimum necessary to accomplish the intended purpose. PHI will not be used for marketing or sale without your specific written authorization. Any use of psychotherapy notes or genetic testing information will be subject to additional protections and require separate authorization.

Patient Rights Under HIPAA

You have the right to: inspect and obtain a copy of your health information; request amendment to information you believe is incorrect or incomplete; request an accounting of disclosures; request confidential communications by alternative means or at alternative locations; and request restrictions on certain uses and disclosures of PHI. Requests must be submitted in writing.

Authorization for Disclosures to Family, Friends, and Others

Unless you object, we may share PHI with family members, other relatives, close personal friends, or any other person you identify who is involved in your care or payment for care. You may restrict this sharing below by specifying persons who should not receive information.

Authorization expiration date (if none specified, authorization remains valid until revoked):

Communications and Messages

Please indicate your preferences for communications about appointments, test results, and billing:

I consent to telephone messages left at my primary phone number.

I consent to receive protected health information by email at the address provided above.

I consent to receive appointment reminders and limited PHI by secure text message.

Acknowledgment and Consent

By signing below, I acknowledge that I have been offered a copy of the practice's Notice of Privacy Practices, which describes how my medical information may be used and disclosed and how I can obtain access to this information. I understand that the practice may change its privacy practices and will provide a revised notice if material changes occur.

I acknowledge that I was offered and received the Notice of Privacy Practices.

I understand that I may revoke any authorization to use or disclose my health information at any time by providing a written revocation to the practice, except to the extent that action has already been taken in reliance on my authorization. I understand that filing a complaint will not affect my treatment, payment, enrollment, or eligibility for benefits.

To file a complaint regarding the handling of my health information, I may contact the practice Privacy Officer at:

Special Authorizations

Certain disclosures of health information require your separate written authorization, including but not limited to disclosures for psychotherapy notes, most uses of PHI for marketing, and disclosures that constitute the sale of PHI. You may execute a separate authorization to permit these disclosures; that authorization is voluntary and may be revoked in writing at any time, subject to legal limitations.

Certification

I have read and understand the policies above or have had them explained to me. I understand my rights regarding the privacy of my health information and the types of uses and disclosures that may be made by the practice. I understand that I may request restrictions and confidential communications, and that the practice will consider such requests in accordance with applicable law.

Sign Now