We understand that your medical and health information is personal. Protecting your health information is important. We follow strict federal and state laws that require us to maintain the confidentiality of your health information. This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations, and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected Health Information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. Please refer to Family Psychiatry Services or Axis I Behavioral Center Notice of Privacy Practices, for a more complete description of such uses and disclosures. Note that you have the right to review the Notice of Privacy Practices prior to signing the consent.
-
With my consent,
Family Psychiatry Services or Axis I Behavioral Center
m
ay use and disclose
protected health information (PIH) about me to carry out treatment, paymen
t and healthcare
operations
.
-
With my consent,
Family Psychiatry Services or Axis I Behavioral Center
may call my home or
other designated location a
nd leave a m
essage on voicemail
or in person in reference to any
items that assists the practice in carrying out
treatment, payment and healthcare operations
s
uch as
a
ppointment reminders
,
i
nsurance items
and any call pertaining to my clinical care
including
laborator
y results
among others.
-
With my consent,
Family Psychiatry Services or Axis I Behavioral Center
may mail to my
address any item that assist the practice in carrying out
treatment, payment and healthcare
operations
such as welcome letters, appointment rem
inders cards, and patient statements, as
long as they are marked Personal and Confidential
.
-
With my consent,
Family Psychiatry Services or Axis I Behavioral Center
can use and disclose
my PHI to carry out
treatment, payment and healthcare operations.
All other uses and disclosures will be made only with your signed consent or authorization. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization. If I do not sign this consent, Family Psychiatry Services or Axis I Behavioral Center may decline to provide treatment to me.