OUR PROMISE OF PRIVACY AND CONSENT TO PATIENT RECORDS

Our office is fully committed to compliance with HIPAA guidelines by:

• Providing appropriate security for our patient records.
• Protecting the privacy of our patient's medical information.
• Appropriately maintaining our information and billing process in compliance with national standards.

If you have any questions or concerns about your services or charges, we encourage you to call the office at 978-459-6737

We reserve the right to change terms of this notice and will inform you by mail of any changes. You then have the right to object to withdrawal provided in this notice. For more information about HIPAA or to file a complaint:

The U.S. department of Health & Human Services

Office of Civil Rights

200 Independence Avenue, S.W. Washington, D.C. 20201

(202)619-0257

Toll Free: 1-877-696-6775

This notice was published and became effective on/or before April 14,2003. We are required by law to maintain the privacy of, and provide individuals with this notice of our legal duties and privacy practice and respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main number.

I acknowledge receipt of the Integrated Gastroenterology Consultants privacy notice. I may request an additional copy of the privacy notice at any time.

Permission to Communicate with Your Primary Care Physician, Other

Community Care Providers and/or Mental Health Providers

In order to ensure continuity of care, it is often necessary to communicate information to your primary care physician and other community care providers including mental health providers, and your insurance company. These communications may include information about your medical treatment and mental health or substance abuse treatment. This information is limited to that which is necessary to determine coverage and the coordination of your care. Many insurance companies require us to document whether or not you will allow your clinician to communicate with your primary care physician, Health Insurance Company and/or mental health providers.

Consent for RX Hub Inquiry 

I hereby provide my consent for Integrated Gastroenterology Consultants to obtain my RX history using the SureScripts-RxHub network. I understand that this inquiry will provide my physician with an accounting of my medication history reported by Pharmacy Benefit Managers and retail pharmacies. I also understand the SureScripts-Rx Hub has certified that RX History Capture follows strict security pro tools to align with HIPAA requirements and respect patient privacy. All queries and responses are made automatically through secure system-to-system communications. 

 

Thank you!