HIPAA | Notice of Privacy Practices

The Department of Health and Human Services has established a “Privacy Rule” to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients’ consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.

As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or health care operations, in order to provide health care that is in your best interest.

We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may have to disclose protected health information for purpose of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent.

You may refuse to consent to the use or disclosure of your protected health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Protected Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent. In order to release any psychotherapy notes separate from this office’s health record, any information the office might use for marketing, or any sale of your information, your consent must be explicitly obtained prior to any of these actions taking place.

If you wish to keep private the results of a test or procedure for which you have paid in full out of pocket, you may request to do so in writing spelling out what information should be restricted and from what insurance company. By doing this, you will ensure that the only people who have knowledge of this information are yourself and the treating physician. It will never be included in the release of your PHI unless you request in writing to do so. Also, as a patient, you have the right to request specific amendments to your PHI by completing an Amendment to PHI Request Form. For more information, please contact the HIPAA Privacy Officer.

If you have any objections to this form, please ask to speak with our HIPAA Privacy Officer. You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.


To our valued patients:

The misuse of Protected Health Information (PHI) has been identified as a national problem. We want you to know that all of our entire staff continually undergoes training so that we may understand and comply with government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the Privacy Rule. We strive to achieve the very highest standards of ethics and integrity in performing services for our patients.

It is our policy to properly determine appropriate use of PHI in accordance with government rules, laws, and regulations. We want to ensure that our practice does not contribute to the growing problem of improper disclosure of PHI. As part of this plan, we have conducted a risk assessment and implemented a Compliance Program that we believe will help us prevent any inappropriate use of PHI.

Mistakes are sometimes made, so it is our policy to listen to our employees and our patients without any thought of penalization if they feel an event in any way compromises our policy of integrity. Questions, complaints and suggestions regarding our HIPAA policies and procedures should be directed to our HIPAA Privacy Officer. Ask any clinic employee for the name and contact information of our HIPAA Privacy Officer.

If a mistake leads to a breach of your PHI, this office will notify you in writing and carry out the respective steps necessary to mitigate the breach.

If you would like an electronic copy of this consent form, please leave your email with the front desk and one will be sent to you.