Patient Hipaa Compliance Consent Form (2013) printable pdf download

Patient H IPAA C ompliance C onsent F orm

The misuse of Personal Health Information (PHI) has been identified as a national problem causing patients

inconvenience, aggravation and money. We want you to know that Albrecht Women’s Care (AWC) and all staff

members continually undergo training so that we may understand and comply with government rules and

regulations regarding the Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on

the “Privacy Rule”. We are required by law to maintain the confidentiality of health information that identifies

you. The Department of Health and Human Services has established a “Privacy Rule” to help insure that your

personal information is protected from unnecessary distribution. The Privacy rule has also been created in order

to p rovide a s tandard f or c ertain h ealth c are p roviders t o o btain t heir p atient’s c onsent f or u ses a nd d isclosures o f

health information about the patient to carry out treatment, payment or health care operations. We strive to

achieve the very highest standards of ethics, integrity, and quality in performing services for our patients. As our

patient, w e w ant y ou t o k now t hat w e r espect t he p rivacy o f y our p ersonal m edical r ecords, a nd w ill d o a ll w e c an

to s ecure a nd p rotect t hat p rivacy. W e s trive t o a lways t ake r easonable p recautions t o p rotect y our p rivacy. N one

of your private information will be released to anyone but you without your expressed written consent. It is our

policy to properly determine appropriate use of PHI in accordance with the governmental rules, laws, and

regulations. We want to ensure that our practice never contributes in any way to the growing problem of

improper d isclosure o f P HI. A s p art o f t his p lan, w e h ave i mplemented a C ompliance P rogram t hat w e b elieve w ill

help us prevent an inappropriate use of PHI. We also want you to know that we support your full access to your

personal m edical r ecords. O ther b usinesses t hat w e d eal w ith m ay h ave i ndirect t reatment r elationships w ith y ou

(such as laboratories that only interact with doctors and not patients). In cases such as these, we may have to

disclose some personal health information for purposes of treatment, health care operations or payment. These

entities a re m ost o ften n ot r equired t o o btain p atient c onsent. Y ou m ay r efuse t o c onsent t o t he u se o r d isclosure

of your personal health information. Should you refuse to disclose your personal health information to us, we

have the right to refuse to treat you under the law. Should you disclose your information to us, but refuse it to

your i nsurance c ompany, y ou w ill b e r esponsible f or t he f ull b alance o n y our a ccount a t t he t ime o f s ervice.

WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE PERSONAL HEALTH INFORMATION (PHI) IN THE

FOLLOWING W AYS

T reatment. Our practice may use your PHI to treat you. For example, we may ask you to have

laboratory tests (such as blood or urine tests), and we may use the results to help us reach a

diagnosis. Any of the people who work for our practice-‐ including, but not limited to, our doctors,

nurses, m edical a ssistants, l aboratory p ersonnel o r i ndirectly w ith a ny p rovider w e r efer y ou t o – may

use or disclose your PHI in order to treat you. Additionally, we may need to disclose your PHI to

others w ho m ay a ssist i n y our c are, s uch a s y our s pouse, c hildren, o r p arents.

Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the

services and items you may receive from us. For example, we may contact your health insurer to

certify that you are eligible for benefits (and for what range of benefits), and we may provide your

insurer with details regarding your treatment and health status to determine if your insurer will

cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from

third p arties t hat m ay b e r esponsible f or s uch c osts, s uch a s f amily o r i nsurance c ompanies. A lso, w e

may u se y our P HI t o b ill y ou d irectly f or s ervices a nd i tems.

Patient Hipaa Compliance Consent Form (2013)