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HIPAA Privacy Regulation and Consent Form

The US Department of Health and Human Services Department (HHS) requires all medical offices to make patients aware that they have rights regarding the use of their personal health information (under the Health Insurance Portability and Accountability Act [HIPAA]).

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing, and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected information, which you can exercise by presenting a written request to the Privacy Officer:

  • The right to request restrictions on certain use and disclosure of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
  • The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
  • The right to inspect and copy your protected health information.
  • The right to amend your protected health information.
  • The right to receive an accounting of disclosures of protected information.
  • The right to obtain paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected information and to provide you with notice of our legal duties and privacy practices with respect to protected information.

You have the right to file written complaint with our office, or with the Department of Health and Human Services about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

You may contact us directly at:
The US Department of Health and Human Services Office of Civil Rights
200 Independence Avenue S.W.
Washington, DC 20201
Phone: 202.619.0257 or 1.877.696.6776

Your signature below is your indication of explanation of your rights and your consent for reports to be sent to these individuals.

Signature and Date Below

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