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HIPAA Consent

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your
privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the
policies have been our practice for years. This form is a “friendly” version. A more complete text is
posted in the office.
What this is all about: Specifically, there are rules and restrictions on who may see or be notified of
your Protected Health Information (PHI). These restrictions do not include the normal interchange of
information necessary to provide you with office services. HIPAA provides certain rights and
protections to you as the patient. We balance these needs with our goal of providing you with quality
professional service and care. Additional information is available from the U.S. Department of Health
and Human Services.
We have adopted the following policies:
Patient information will be kept confidential except as is necessary to provide services or to ensure
that all administrative matters related to your care are handled appropriately. This specifically
includes the sharing of information with other healthcare providers, laboratories, health insurance
payers as is necessary and appropriate for your care. Patient files may be stored in open file racks
and will not contain any coding which identifies a patient’s condition or information which is not
already a matter of public record. The normal course of providing care means that such records may
be left, at least temporarily, in administrative areas such as the computer desktop, if applicable the
front office, examination room, etc. Those records will not be available to persons other than office
staff. You agree to the normal procedures utilized within the office for the handling of charts, patient
records, PHI and other documents or information.
It is the policy of this office to remind patients of their appointments. We may do this by telephone,
e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may
send you other communications informing you of changes to office policy and new technology that
you might find valuable or informative.
The practice utilizes a number of vendors in the conduct of business. These vendors may have
access to PHI but must agree to abide by the confidentiality rules of HIPAA.
You understand and agree to inspections of the office and review of documents which may include
PHI by government agencies or insurance payers in normal performance of their duties.
You agree to bring any concerns or complaints regarding privacy to the attention of the office
manager or the doctor.
Your confidential information will not be used for the purposes of marketing or advertising of
products, goods or services.
We agree to provide patients with access to their records in accordance with state and federal laws.
We may change, add, delete or modify any of these provisions to better serve the needs of both the
practice and the patient.

You have the right to request restrictions in the use of your protected health information and to
request change in certain policies used within the office concerning your PHI. However, we are not
obligated to alter internal policies to conform to your request.

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