Patient Acknowledgement Of The Notice Of Privacy Practices And Consent Form printable pdf download

Patient Acknowledgement Of The Notice Of Privacy Practices And Consent Form

PATIENT ACKNOWLEDGEMENT OF THE NOTICE OF PRIVACY

PRACTICES AND CONSENT FORM

The Department of Health and Human Services has established a “Privacy Rule” to help

insure that personal healthcare information is protected. The privacy rule was created in

order to provide a standard for certain health care providers to obtain their patient’s

consent for uses and sharing with others health information regarding payment and

healthcare operations.

As our patient, we want you to know that we respect the privacy of your personal medical

records and will do all that we can to secure and protect that privacy. We strive to always

take reasonable precautions to protect your privacy. When it is appropriate and

necessary, we provide only the minimum necessary information to those we feel are in

need of your information in order to provide the care that is in your best interest.

We also want you to know that we support your full access to your personal medical

records. We may have indirect relationships with others (for example a laboratory) and

may have to disclose personal health information for the purpose of treatment, payment

or healthcare operations. These partners in your healthcare are also most often not

required to obtain patient consent.

You may refuse to consent to the use or disclosure of your personal health information,

but this must be in writing. Under this law, we have the right to refuse to treat you

should you choose to refuse to disclose all or part of your personal health information

(PHI).

If you choose to give consent in this document, at some future time you may request to

refuse to release all or part of your PHI. You may not revoke your decisions that have

already been taken which relied on this or a previously signed consent.

Our NOTICE OF PRIVACY PRACTICES describes in detail how much medical

information about you may be used or shared and how you can get access to that

information. There is a current copy of this notice available in the lobby of each Pioneer

Physicians Network, Inc. medical office and a full and complete copy will be offered to

you at no charge. You have the right to review our privacy notice, to request restrictions

and revoke consent in writing after you have reviewed our privacy notice. If you have

any questions or objections to this form, please ask to speak with the Office Manager or

our HIPAA Privacy Officer.

Thank You!

_________________________

_______________________ Date____/____/____

Signature

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Patient Acknowledgement Of The Notice Of Privacy Practices And Consent Form