The Health Insurance Portability and Accountability Act (HIPAA) safeguards your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. This form is a “friendly” version. A complete text can be found at

What this is all about:

There are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the standard interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as a patient. We balance these needs with our goal of providing quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services.

We have adopted the following policies:

Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This includes sharing information with other healthcare providers, laboratories, and health insurance payers as necessary and appropriate for your care. Patient files may be stored in open file racks. They will not contain any coding that identifies a patient’s condition or information that is not already public record. The ordinary course of providing care means that such records may be left temporarily in administrative areas such as the front office and examination room. Those records will not be available to persons other than office staff. You agree to the standard procedures utilized within the office for handling charts, patient records, PHI, and other documents or information.

It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S. mail, or any means convenient for the practice and as requested. We may send you other communications informing you of changes to office policy and new technology that you find valuable or informative.

The practice utilizes several vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.

You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in the typical performance of their duties.

You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.

Your confidential information will not be used to market or advertise products, goods, or services.

We agree to provide patients access to their records following state and federal laws.

We may change, add, delete, or modify any of these provisions to better serve the needs of the practice and the patient.

You have the right to request restrictions in using your protected health information and to request a change in specific policies used within the office concerning your PHI. However, we cannot alter internal policies to conform to your request.

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