HIPAA NOTICE OF PRIVACY PRACTICES
The HIPAA privacy rule gives individuals the right to request information regarding the use and disclosures of their protected health information (PHI). By signing I agree that I have been counseled on and understand the notice. The full notice is available upon request and available for download off our website.
The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use of disclosure of, and the requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization request by the individual.
Healthcare entities must keep records of PHI disclosures. Information provided below if complete properly, will constitute an adequate record.
NOTE: Uses and disclosure for TPO may be permitted without prior consent in an emergency.
The following names listed are those that I give G&H Healthcare the authorization for disclosure of my health information:
Name _______________________________ Relationship ______________________________
Acknowledgement of Receipt of Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Practices and Consent
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. It also provides the information about our rights as a patient of our practice and whom you may contact at our office to ask questions about our privacy practices.
By signing this form, I hereby acknowledge that I have had the opportunity to read the Notice of Privacy Practices of G&H Healthcare and understand that in compliance with that notice, G&H Healthcare is allowed to use or disclose my individually identifiable health information for the purpose of treatment, payment, and health care operations. I further understand that the Notice of Privacy Practices provides a more complete explanation of the use or disclosure of my individually identifiable health information.
I have read a copy of the G&H Healthcare HIPAA Notice of Privacy Practices and understand the information it contains.
_____________________________________________________________________________________
Patient's Signature/Power of Attorney/Guardian or Representative
_____________________________
Date