understand that, under The Health Insurance Portability Accountability Act (HIPAA) of 1996, I have certain rights to privacy in regards to my protected health information (PHI HIPAA requires my medical provider by law to maintain the privacy of my personal health information and to provide me with notice of legal duties and privacy policies with respect to my personal health information. I am required by law to abide by the terms of this Privacy Notice. I understand that personal health information is collected from me through treatment, payment, the application and enrollment process, and/or healthcare providers, health plans, and through other means, as applicable. A health care provider or health plan may send copies of my records to another provider or health plan, as needed, for treatment by my authorization. My personal health information broadly includes any information, oral, written or recorded, that is created or received by certain health care entities, including health care providers, as well as, health insurance plans and is protected by law. The law specifically protects data, such as my name, address, social security number and other data that could be used to identify me as the individual patient who is associated with that health information.
| understand that generally, my personal health information will not be disclosed without my permission. However, without my consent, I acknowledge that my information may be used to the extent of requirement by law. This practice is required to keep my patient medical records for 7.5 years starting from the most recent date of service by law of NYS Dept. of Health Records Retention, Policy Statement 08-03 as of 4/3/2008.
I understand that this practice reserves the right to change the terms of its Notice of Privacy Policy. I have received, read, understood and consent to The Notice of Privacy Policy.