HIPAA PRIVACY COMPLIANCE POLICY EFFECTIVE 6/01/09
We Will Keep Your Medical Information Confidential
THIS NOTICE IS PRESENTED IN COMPLIANCE WITH FEDERAL HIPAA REQUIREMENTS FOR HEALTH CARE PROVIDERS AND DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
HIPAA “The privacy provisions of the federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), apply to health information created or maintained by health care providers who engage in certain electronic transactions, health plans, and health care clearinghouses. The Department of Health and Human Services (HHS) has issued the regulation, "Standards for Privacy of Individually Identifiable Health Information," applicable to entities covered by HIPAA. The Office for Civil Rights (OCR) is the Departmental component responsible for implementing and enforcing the privacy regulation. (See the Statement of Delegation of Authority to the Office for Civil Rights, as published in the Federal Register on December 28, 2000.”
Question: What is this HIPAA compliance form all about?
Answer: HIPAA requires all Health Care Practitioners to keep your health-related information
private, releasing us to release pertinent information to:
Your insurance company or other 3rd party payer, so they can pay your bill.
Your other doctors, for information you want them to have from us.
Your attorney or anyone else you request and authorize us to release it to.
Our business partners. Examples: Outside billing companies, outside marketing companies that might produce and mail our newsletters, etc. If we use any such company, they too will maintain the same level of privacy we maintain.
Your legal representative(s), should you for any reason become unable to speak and or act for yourself in making health care related decisions.
Your providers of emergency treatment as consistent with our awareness of your needs and the doctor’s best judgment.Example: You are in the emergency room and they need medical information about you from us.
Your family, friends or others that may answer your phone, read your mail, or otherwise communicate with us as part of our exchanging information with one another that is necessary to your care and relationship with this office. Examples: We can call your home and leave a message for you on your answering machine or with any person that answers. We can send you a fax or e-mail that might be read by any other person with access to your fax or e-mail. We can leave a message for you at work on any recording device or with any person limited to our name, phone number, and the level of necessity /urgency that you contact us.
You should be aware that government agencies can abridge your right to privacy and legally require us to release information even against your will. Examples: In cases of child abuse where the parent does not authorize the release of this information. In instances where you might be a threat to yourself or others (i.e., suicidal). The office will obey the law in respect to any current or future requirements to report or release information.
The treatment rooms are not enclosed, and the patient is aware that unless otherwise requested, information relevant to their visits will be discussed in the treatment rooms. The patient can request that they speak with the Doctor regarding test results, information specific to their care and other relevant information be discussed in an enclosed room if one is available.
YOU CAN REVIEW, RESTRICT AND/OR REVOKE ACCESS TO YOUR INFORMATION
Space is provided on subsequent pages of this form for you to list any objections, restrictions, limitations etc. that you want to apply to your information in our office. This can include the names of individuals that are to have no or limited access to your information and if limited the parameters of that limitation. Example: The name of your 14-year-old child where you allow that we can leave messages for you but not discuss the details of your health. You can update this information at any time, in person or over the phone. Example: You still live with a significant other, but you no longer want us to leave any messages with them.
By signing below, I acknowledge that I understand and agree to the above and can request a copy of this notice. I have indicated any restrictions I wish to apply to my records on the reverse side of this page.