To our patients: This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you cangetaccessto
your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA
Our commitment to your privacy
Our practicededicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following important information.
Use and Disclosure of Your Health Information in Certain Special Circumstances The following circumstances may require us to use or disclose your health information:
1.To public health authorities and health oversight agencies that are authorized by law to collect information. 2.Lawsuits and similar proceedings in response to a court or administrative order. 3.If required to do so by a law enforcement official. 4.When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosure to a person or organization able to help prevent the threat. 5.If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. 6.To federal officials for intelligence and national security activities authorized by law. 7.To correctional institutions or law enforcement officials if you are an inmate or under the custody of law enforcement official. 8.For Workers Compensation and similar programs.
Your rights regarding your health information:
You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operation. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment forcare, your suchas family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.
PATIENT CONSENT FOR Use AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
I have the right to review the Notice of Privacy Practices prior to signing this consent. Endless Vitality and its providers reserve the right to revise this Notice of PrivacyPractices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Endless Vitality Privacy Officer at 1845 E Broadway Rd Suite 116 Tempe, AZ 85282.
With my consent, Endless Vitality and it providers and staff may call my home or to other designated location and leave a message on a voice mail or in person in reference to any items that assist the practice in carry out TPO; such as appointment reminders, insurance items, and any call pertaining to my clinical care, including laboratory results among others.
TPO, With my consent, Endless Vitality and its providers and staff may mail to my home or other designated location any items that assist the practiceincarryingout such as appointment reminder cards and patient statements as long as they are marked personal and confidential.
Bythis form, I am consenting to Endless Vitality providers and staff to use and disclosure of my Personal Health Information to carry out treatment, payment signing and healthcare operations. I have also read the Notice of Privacy Practices.
I may revoke my consent in writing except to the extent that the practice has already made disclosure in reliance upon my prior consent. If I do not signthisconsent, Endless Vitality may decline to provide treatment to me.
I herby acknowledge that I have been presented with a copy of Endless Vitality Notice of Privacy Practice