This summary of our privacy practices contains a condensed version of our Notice of Privacy Practices. Our full length notice is posted in the reception area and a copy of the full length is available for you at the checkout desk.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY HAVE ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We understand that your medical information is personal to you and we are committed to protecting your information about you. As our patient, we create medical records about your health, our care for you, and the services/and or items we provide to you as our patient. By law, we are required to make sure that your information is protected and kept confidential.
You, as the patient, have certain rights regarding the information we maintain about you. All requests must be made in writing, with a 48 hour notice, no exceptions. Our medical records staff/department will assist you with the written requests. These rights include:
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE
Our Notice of Privacy Practices provides information about how we use and disclose protected health information about you. Your have the right to review our notice before signing this consent. As provided in our notice, the terms of our notice can change. If we change our notice, you may obtain a revised copy of this by contacting the office. You have the right to inspect that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement.
By signing this form, you (or your representative) consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.