1. As a patient, this notice is to inform you that we are in compliance with the law concerning privacy of your health information, HIPAA. This is a short summary; the full length explanation of HIPAA is available to you upon request. If you are concerned about how we may use your information, please read the long version called, “Notices of Privacy Practices.” By signing our form, you acknowledge the understanding of this Notice. You will be given a link to sign online forms when scheduling your appointment, or a paper copy.
We, at this clinic, do not share your protected health information (PHI) nor any personal information with anyone other than with an entity that you agree to share information with. By signing this form, you agree to allow us to use your information for pertinent reasons: products and services, healthcare operations, and billing for payment of products and services. These reasons are fully described in the “Notices of Privacy Practices.” This type of information includes your name, social security number, birth date, address, insurance company, phone numbers, your health history questionnaire, and any and all related medical charting in regards to products or services we provide to you.
Patients can request to have anyone accompany them in the room during treatment. The patient then acknowledges that personal health information may be shared with this person. We do not share your PHI with anyone else in the clinic other than those listed here or pertinent staff of the clinic for the purpose of clinic operations.
We have the right to contact you by phone, mail, or email if you list this information in your consent form. This contact could be regarding scheduling, promotions, or other pertinent reasons of the clinic, but we will not give PHI to anyone else as a result of these types of contact.