HIPAA / Patient Health Information (PHI)
We want you to know how your Patient Health Information (PHI) will be used in this office and your rights concerning those records. Before we begin any healthcare operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information, we encourage you to read the HIPAA Notice that is available to you in our waiting area. The patient understands and agrees to allow this office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operation & coordination of care. For example, the patient agrees to allow this office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment.
The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit any further restrictions on using their PHI in writing. Our office(s) must agree to those restrictions only to the extent they coincide with state and federal law. A patient’s written consent need only be obtained one time for all subsequent care given to the patient in this office.
The patient may provide a written request to revoke consent at any time during care. This would no affect the use of those records for the care given before the written request to revoke consent but would apply to any care given after the request has been presented.
Our office may contact you periodically regarding appointments, treatments, products, services or charitable work performed by our office. You may opt out of any marketing or fundraising communication at any time.
For your security and right to privacy, all staff has been trained in the area of patient record privacy, and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to ensure that your records are not readily available to those who do not need them.
Patients have the right to file a formal complaint with our privacy official and the Secretary of HHS about any possible violations of these policies and procedures without retaliation by this office.
Our office reserves the right to make changes to the notice and make the new notice provisions effective for all protected health information it maintains. You will receive a new notice at your next visit following any change.
If the patient refuses to sign this consent for the purpose of treatment, payment, and health care operations, the therapist has the right to refuse to give care.
This notice is effective on the date of your signed consent.