CTL Confirm-IT2 - Manual (Page 40)

Appendix A
Confirm-IT2 User Guide
36
APENDIX A
HIPAA Information and Consent Form
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. This form is a “friendly” version. A more complete text is posted in the office.
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. www.hhs.gov
We have adopted the following policies:
1. 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 specifically includes the sharing
of information with other healthcare providers, laboratories, health insurance payers as is necessary and
appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which
identifies a patient’s condition or information which is not already a matter of public record. The normal
course of providing care means that such records may be left, at least temporarily, in administrative areas
such as the front office, examination room, etc. Those records will not be available to persons other than
office staff . You agree to the normal procedures utilized within the office for the handling of charts, patient
records, PHI and other documents or information.
2. 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 by any means convenient for the practice and/or as requested by you. We may send you other
communications informing you of changes to office policy and new technology that you might find valuable
or informative.
3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to
PHI but must agree to abide by the confidentiality rules of HIPAA.
4. You understand and agree to inspections of the office and review of documents which may include PHI by
government agencies or insurance payers in normal performance of their duties.
5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manger or
the doctor.
6. Your confidential information will not be used for the purposes of marketing or advertising of products,
goods or services.
7. We agree to provide patients with access to their records in accordance with state and federal laws.
8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the
practice and the patient.
9. You have the right to request restrictions in the use of your protected health information and to request
change in certain policies used within the office concerning your PHI. However, we are not obligated to alter
internal policies to conform to your request.
I, _______________________________date____________ do hereby consent and
acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and
any subsequent changes in office policy. I understand that this consent shall remain in
force
from this time forward.