HIPAA Compliance Forms Below
Protecting Your Health Information and your Privacy
Dear Valued Patient,
This notice describes my office’s policy around how medical information about you may be used and disclosed, how you can get access to this information, and how your privacy is being protected.
In order to maintain the level of service that you expect from my office, I may need to share limited personal medical and financial information with your insurance company with Workman’s Compensation (and your employer as well in this instance), or with other medical practitioners that you authorize.
Safeguards in place at my office include:
� Policies and procedures for handling information.
� Limited access to facilities where information is stored.
� Requirements for third parties to contractually comply with privacy laws.
� All medical files and records (including email, regular mail, telephone, and faxes sent) are kept on permanent file.
Types of information that I gather and use:
In administering your health care, I gather and maintain information that may include non-public personal information.:
� From your medical history, treatment notes, all test results, and any letters, faxes, emails or telephone conversations to or from other health care practitioners.
� About your financial transactions with me (billing transactions).
� From health care providers, insurance companies, workman’s comp and your employer, and other third part administrators (e.g. requests for medical records, claim payment information).
In certain states, you may be able to access and correct personal information I have collected about you,
(information that can identify you - e.g. your name, address, Social Security number, etc.).
I value our relationship and respect your right to privacy. If you have questions about my privacy guidelines, please call me at 773-312-9061.
Sincerely,
Dr. Phranque Wright DAOM
Phranque Wright Dipl. Ac., Licensed Acupuncturist
4007 N Broadway Chicago, IL 60613
Policy Regarding the Protection of
Your Health Information and Your Privacy
I, Phranque Wright, DAOM Licensed Acupuncturist,
will responsibly use your individually identifiable health information (referred to as “confidential information”.) This includes information that is created or received by a health care provider, health plan, or your employer (in the case of Workman’s Compensation). It also includes information related to your past, present and future physical and mental health, and payment for the provision of your health care.
I, Phranque Wright, DAOM., Licensed Acupuncturist, may use and/or disclose your confidential information without your authorization for the following purposes:
� Providing treatment, payment, or health care operations.
� Billing, and getting authorization for treatment from insurance companies and Workman’s Compensation.
� Providing appointment reminders or information about treatment alternatives, other health related benefits, and services.
� I may also use/and or disclose your confidential information without your authorization as permitted or required by law, ( i.e. to a public health authority or to the FDA, or for work related illness or injuries, or to the sponsor of a group’s health plan, health insurance issuer, or HMO).
Your authorization is required for Dr. Phranque Wright, DAOM, Licensed Acupuncturist to use your confidential information (if you choose) to other health care providers or other individuals to receive information about you. You may revoke that authorization in writing at any time.
You have the right to
� Request an alternate address or method of contacting you.
� Inspect and copy your confidential information.
� Request restrictions on certain uses or disclosures; however, these restrictions are subject to agreement by Phranque Wright, Dipl. Ac., Licensed Acupuncturist.
� Receive an accounting of the disclosures I make involving your confidential information.
� Amend your confidential information (in limited situations).
Phranque Wright, DAOM, Licensed Acupuncturist will maintain the privacy of confidential information as required by law and by the notice currently in effect. I am also required by law to provide this notice of my legal duties and privacy practices related to protected health information. This notice is effective April 14, 2003. I reserve the right to make changes or revisions to the terms of this notice, and will make available at my office a new notice if any material changes are made.
If you believe that your rights have been violated, you may contact me or the secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint. You may send information to either party at the appropriate address listed below:
� Phranque Wright, DAOM., Licensed Acupuncturist
4007 N Broadway Chicago, IL 60613
� Department of Health and Human Services
200 Independence Avenue S.W., Washington, D.C. 20201
If, for any reason, you wish to have your information shared, you can use this document to
list the names of people or entities with whom I can share your informeation.
Your information will not be shared without this form filled out unless it is required by law.
You may cut and paste this information or ask for a copy to be sent to you.
Dear Valued Patient,
No medical information with any third parties will be discussed, unless written consent/authorization has been obtained from you. (This includes by telephone, fax, letter, e-mail, or in person.) This consent form gives me permission to do so.
For the purpose of administering my health care and related activities, I hereby agree, on my behalf and behalf of my minor dependents, that information available regarding medical records, on behalf of myself or my minor dependents, may be released by Phranque Wright, Dipl. Ac., Licensed Acupuncturist, to me, to my spouse, my parents (for dependents age 18 or over), my medical providers, my medical insurance providers, Workman’s Compensation, or my employer, as applicable, or as may be otherwise lawfully permitted, or as I may further authorize in the box below.
Optional Additional Authorized Individuals – please print clearly.
I authorize the following individuals(s) to receive the above-named information.
_______________________________, ________________________________
Full name………………………………….Relationship to patient
_______________________________, _________________________________
Full name………………………………….Relationship to patient
Please note: An authorization is not needed for disclosures related to my or my minor dependents’ treatment, the payment for such treatment, or related health care operations as defined under 45 CRF part 160 and 164, Standards for Privacy of Individually Identifiable Health Information. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the authorized recipient and may no longer be protected by state or federal law.
You may request a copy of this authorization. You may revoke authorization at any time in writing. You may refuse to sign this authorization. You have the right to request access to your protected health information that may be used or disclosed.
Patient signature…………………………………….date
Signature of Covered Dependent if 18 or over………….date