The Health lnsurance Portability and AccountabilityAct of 1996 (HIPAA) provides safeguards to protect
your privacy. These safeguards include restrictions on who may see or be notified of your Protected
Health lnformation (PHl). These restrictions do not include the normal interchange of information necessary
to provide your or your family with treatment. HIPAA provides certain rights and protections to you as
the patient. We must balance these needs with our goal of providing you with quality service and care.
Additional information is available by calling the U. S. Department of Health and Human Services or at:
For this reason, our practice has adopted the following policies:
(1) Patient information will be kept confidential except as is necessary to provide treatment or to
ensure that all administrative matters related to your care are handled appropriately. This speciflcally
includes the sharing of information with other healthcare providers, laboratories, as is necessary and
appropriate for your care. Patient files may be stored in open file racks but 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 in administrative areas such as the
front office, Doctor’s office, etc. The patient agrees to the normal procedures utilized within the facility for
the handling of charts, patient records, PHI and other documents or information.
(2) lt is the policy of the office to remind patients of their appointments. This may be done by
telephoning patients or by any other means convenient for the practice.
(3) The practice utilizes a number of vendors in the conduct of business. These vendors may have
access to PHI but agree to abide by the confidentiality rules of HIPAA.
(4) The patient understands and agrees to inspections of the office and the review of documents
which may include PHI by government agencies or insurance companies in the normal performance of
(5) The patient agrees to bring any concern or complaints regarding privacy to the attention of the
Doctor or office manager.
(6) Your confidential information will not be used for purposes of advertising or marketing of products,
goods or services. Such prohibition does not include treatment/product samples or goods of nominal
(7) The practice agrees to provide the patient with access to their records in accordance with state
(8) The practice may change, add, delete, or modify any of these provisions to better serve the
needs of 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 changes in certain policies used within the office concerning your PHl. However, the practice is
under no obligation to alter internal policies to conform with your request.
(10) There is no patient right to litigation under HIPAA.
HIPAA Consent & Acknowledgment Form
I ______________________________ do hereby Consent and Acknowledge my agreement to
Patient or Guardian Signature
the terms set forth in the “HIPAA INFORMATION FORM” and any subsequent changes in office policy. I
understand that this consent and acknowledgment shall remain in force indefinitely.