The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. 

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. Protected health information includes demographic and medical information that concerns the past, present, or future physical or mental health of an individual. Demographic information could include your name, address, telephone number, social security number, and any other means of identifying you as a specific person. Protected health information contains specific information that identifies a person or can be used to identify a person.


Protected health information is health information created or received by a health care provider, health plan, employer, or health care clearinghouse. This medical information is used by the practice in many ways while performing normal business activities.


Your protected health information may be used or disclosed by the practice for purposes of treatment, payment, and health care operations. Healthcare professionals use medical information in the clinics or hospitals to take care of you. Your protected health information may be shared, with or without your consent, with another healthcare provider for purposes of your treatment. Some protected health information can be disclosed without your written authorization, as allowed by law. Those circumstances include:

Legislature’s Office of Program Policy Analysis and Government Accountability.

Surveillance, investigations, interventions, and regulation of health professionals.



You have the right to request the practice to restrict the use and disclosure of your protected health information to carry out treatment, payment, or health care operations. You may also limit disclosures to individuals involved with your care. The practice is not required to agree to any restriction.

You have the right to be assured that your information will be kept confidential. The practice will make contact with you in the manner and at the address or phone number you select. You may be asked to put your request in writing. If you are responsible to pay for services, you may provide an address other than your residence where you can receive mail and

where we may contact you.

You have the right to inspect and receive a copy of your protected health information that is maintained by the practice within 30 days of the practice’s receipt of your request to obtain a copy of your protected health information. You must complete the practice’s Authorization to Disclosure Confidential Information form and submit the request to the county health department or Children’s Medical Services office. If there are delays in getting you the information, you will be told the reason for the delay and the anticipated date when you will receive your information.

Your inspection of information will be supervised at an appointed time and place. You may be denied access as specified by law.

If you choose to receive a copy of your protected health information, you have the right to receive the information in the form or format you request. If the Department cannot produce it in that form or format, it will give you the information in a readable hard copy form or another form or format that you and the practice agree to.

The practice cannot give you access to psychotherapy notes or certain information being used in a legal proceeding. Records are maintained for specified periods of time in accordance with the law. If your request covers information beyond that time the Department is required to

keep the record, the information may no longer be available.



If access is denied, you have the right to request a review by a licensed healthcare professional who was not involved in the decision to deny access. This licensed healthcare professional will be designated by the Practice. You have the right to correct your protected health information. Your request to correct your protected health information must be in writing and provide a reason to support your requested correction. The Practice may deny your request, in whole or part, if it finds the protected health information:

If your correction is accepted, the practice will make the correction and tell you and others

who need to know about the correction.

                       Summary of HIPAA PRIVACY POLICIES: 

I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA Information Form and any subsequent changes. I understand that the consent shall remain in force from this time forward.