It is the policy of our clinic to preserve the integrity and confidentiality of protected health information (PHI) pertaining to our patients. The purpose of this policy is to ensure that our clinic and its physicians and staff have the necessary medical and PHI to provide the highest quality medical care possible while protecting the confidentiality of the PHI of our patients to the highest degree possible.

PHI is defined as any information whether oral or recorded, in any form or medium, that is created or received by a healthcare provider that connects the patient’s name to any treatment, financial status, or health status in the past, present, or future. PHI is generally used when we send and receive information to/from doctors, lawyers, pharmacies, and insurance companies.

If PHI is requested by another office or by the patient, we request the patient sign a release form before any information can be shared or released. There is an understanding that we may send PHI if requested by your insurance company in order to secure payment (when applicable) for you or us.

Only the minimum information necessary will be shared, as a rule. Disclosure of PHI in the following cases does not require patient consent:

Patients have the right to receive a copy of this Notice of Privacy Practices. It will always be available online. They have the right to access their own PHI and to request amendments and restrictions. Patients have the right to not be intimidated or threatened when making these requests. We may not require them to sign a waiver, relinquishing these rights, in order to receive treatment. Patient’s names will not be used in any fundraiser or venture without prior authorization.

Unless we are otherwise directed, PHI will only be released to friends and/or family if the patient is incapacitated or it is an emergency and ONLY if the doctor decides that is in the best interest of the patient. If you have family members who you would like to authorize access to your PHI, please list their names below. Custodial parents have access to their children’s PHI if they are minors unless another agreement has been made if the doctor believes there is a possibility of child abuse or neglect.

If a patient requests an amendment of, or access to their PHI, depending on the situation, the doctor may or may not comply. If access or amendments are denied, the patient will be provided with a statement that includes the reasons for that denial. Our office has 30 days to respond to any request for information. If the requested information is kept offsite, our office has 60 business days to respond. If the patient does not agree with the doctor’s decision, there is an appeals process that will be explained to the patient at that time.

I have read the above notice and acknowledge the privacy practices as written above.