**********PHYSICIAN AND STAFF/PRIVACY***********
*********************WANT YOU TO KNOW***********************
*******WE WILL PROTECT YOUR PRIVATE HEALTH INFORMATION*******
When you visit our office it is very important that you feel safe in telling your Doctor personal information that may be required to fully diagnose or treat a problem. As medical professionals, please be assured that our practice has always had strict policies and procedures to protect the confidentiality of the information that you have entrusted to us. However, on April 14th, 2003, new regulations became effective under a federal law called the Health Insurance Portability and Accountability Act "HIPPA". These regulations cover Physicians and all other Health Care providers, as well as, Health Insurance companies and their claims processing staff. In general, HIPPA was enacted to:
1. Give patients more control over their Health information.
2. Set boundaries for the use and release of health records.
3. Establish safeguards that Physicians, Health Plans, and other health care providers must have in place to protect the privacy of health information.
4. Hold violators accountable with civil and criminal penalties
5. Try and balance the need for individual privacy with the requirement for public responsibility that requires disclosure to protect the public health.
The HIPPA rules require that our practice provide all of our patients that we see after April 14th, 2003 with our Notice of Privacy Practices. The Notice describes how the medical information we receive from you may be used or disclosed by our practice and your rights related to your access to this information. A copy of this Notice is posted by the waiting room, and a copy is available to you if desired, at the check-out window.
Please sign below that we have made a copy of this Notice available for you to review. You are entitled to a personal copy of the Notice at any time to review and keep for your records. If you have any questions about our Privacy Practices, please feel free to contact our Office Manager.
Additionally, by signing below, I allow anyone who enters the examination and/or consultation room with me to participate in examination(s) and/or discussion regarding my health care while in my presence.
Thank You for your cooperation.
I HEREBY ACKNOWLEDGE THAT I HAVE RECEIVED A COPY OF OUR PRIVACY PRACTICES AND HAVE BEEN GIVEN THE OPPORTUNITY TO ASK QUESTIONS.
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BY PRINTING YOUR NAME ABOVE AND CHECKING THE BOX BELOW, I ATTEST THAT THIS QUALIFIES AS MY OFFICIAL SIGNATURE AND CONSIDER THIS DOCUMENT OFFICIALLY SIGNED BY ME AND OR MY GUARDIAN.
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By signing below you agree to a full knowledge and understanding of our