HIPAA Consent
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
We are committed to protecting the privacy of our patients’ personal and health information. All of our employees are required to sign confidentiality agreements and are required to comply with our confidentiality policy.
We may use or disclose your protected health information for purpose of treatment, payment, or practice operations only with your written consent. For example, we may contact another physician to coordinate your care, submit a claim to an insurer, or look at your file to perform internal quality monitoring. We must obtain your written authorization at any time in writing. This will not apply to information used or disclosed while the consent or authorization is in effect.
We will provide access to your information, without your cone tor authorization, when required to do so by law or regulation. Access may be granted to public health and law enforcement authorities, health care oversight agencies, government benefit programs, employers (in cases of work-related illness or injury), courts, and administrative tribunals.
We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services. You may want a friend or family member to discuss care with a physician(s), or a staff member, take messages, and pick up prescriptions or other medically related communications.
Please indicate if there is a friend or family member to whom we are allowed to release medical information to: