HIPPA Consent for Use of Disclosure of Health Information
We are concerned with protecting your privacy. While the law requires us to give you this disclosure, please understand that we have, and always will, respect the privacy of your health information. There are several circumstances in which we may have to use or disclose your health care information.
We may need to disclose your health information to another health care provider of a hospital if it is necessary to refer you to them for the diagnosis, assessment or treatment of your health condition.
We may have to disclose your health information to another party if they are potentially responsible for the payment of services you receive.
We may need to use your health information within our practice for quality control or other operational purposes.
We have a complete notice in the lobby of our office that provides a detailed description of how your health information may be used or disclosed as per HIPPA (Health Insurance Portability and Accountability Act of 1996). After reading this form and/or reviewing the notice in the lobby, you may place restrictions on our use of your information in writing. We are not required to agree to your restrictions.
If you revoke your authorization consent, it must be in writing. Your insurance company may have the right to your health information if they decide to contest any of your claims.