HIPAA Disclosure – Confidentiality Agreement

HIPAA Disclosure – Confidentiality Agreement

Information about one’s health, health care, and payment for health care is called Protected Health Information (PHI). We safeguard your PHI and provide you this notice summarizing our privacy practices. It describes how, when, and why your medical information may be used and disclosed.

We ask that you please review it carefully.

*Note, our privacy practices and the terms of this notice may change at any time. If we revise the notice, at your request, we can provide you with an updated Notice of Privacy Practices. You may ask for a copy either electronically, by mail, or in person.

We may use and disclose your Protected Health Information as follows without your permission:

For treatment purposes.
We may disclose your health information to doctors, nurses, and others who provide your health care. For example, the information may be shared with people performing lab work or x-rays.

To secure payment.
We may disclose your health information in order to collect payment for health care services rendered or to be rendered.

For health care operations.
We may use or disclose your health information to contact you to remind you of your appointment or to call you by name in the waiting room when your doctor is ready to see you.

When required by law.
We may be required to disclose your Protected Health Information to law enforcement officers, courts, or government agencies. For example, we may have to report abuse, neglect, or certain physical injuries.

For public health activities.
We may be required to report your health information to government agencies to prevent or control disease or injury.
We also may have to report work-related illnesses and injuries to your employer so that your workplace may be monitored for safety.

For health oversight activities.
We may be required to disclose your health information to government agencies so that they can monitor or license health care providers such as doctors and nurses.

To avert a threat to health or safety.
In order to avoid a serious threat to health or safety, we may disclose your health information to law enforcement officers or other persons who might prevent or lessen that threat.

Patient Rights:
You may request a copy of your Protected Health Information, in most cases. You may not view information collected for use in legal or government action, or information which you cannot access by law. As we use and maintain your PHI electronically, you may request it in electronic format.

You may ask us to limit how we use or disclose your information. We cannot limit uses or disclosures that are required by law.

To request confidential communication methods. You may ask that we contact you at a certain address or in a certain way.

NOTE: Any of the patient request, may be denied at the discretion of the practice.

If you have questions about this Notice or about our privacy practices, please contact our office.

Effective Date 7/1/22