HIPPA Disclosure

Definition of "Protected Health Information": Health information, including demographic information collected from me as well as that created or recieved by my physician, another health care provider, a health plan, my employer, or a health care clearinghouse. this PHI relates to my past, present, and future physical or mental health or condition and identifies me, or for which there is a reasonable base to believe the information may identify me.

I understand I have the right to review the Practice's Notice of Privacy Practices prior to signing this document. The practice's Notice of Privacy Practices is posted and is available for me for inspection in the waiting room of the Practice and a writteen copy has been or will be provided to me me upon request. Notice of Privacy Practices describes the types of uses and disclosures of my PHI that will occur in my treatment, payment of my bills, or in the performance of health care operations of the Practice. The Notice of Privacy practices also describes my rights and the Practice's duties with respect to my PHI.

The practice reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting that a revise copy be sent by mail or by asking for one at the time of my appointment.