Patient Consent for Use and Disclosure of Protected Health Information
I have reviewed and received a copy of the HIPP prior to signing this consent. Jordan Hoffman Acupuncture reserves the right to revise its HIPP at anytime without notice to me. A revised HIPP may be obtained by submitting a written request to Jordan Hoffman Acupuncture.
With my consent, Jordan Hoffman Acupuncture may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any information pertaining to my clinical care.
With my consent, Jordan Hoffman Acupuncture may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminders cards and patient statements as long as they are marked Personal and Confidential.
With my consent, Jordan Hoffman Acupuncture may email to me appointment reminder cards and patient statements. I have the right to request that Jordan Hoffman Acupuncture restrict how it uses or discloses my PHI to carry out TPO. However, Jordan Hoffman Acupuncture is not required to agree to my requested restrictions.
By signing this form, I am consenting to Jordan Hoffman Acupuncture’s use and disclosure of my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Jordan Hoffman Acupuncture may decline to provide treatment to me.
This notice describes Jordan Hoffman Acupuncture’s policy for 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 our office, we may need to share personal medical and financial information with your insurance company, with worker’s compensation (and your employer as well in this instance), or with other medical practitioners or others that you authorize.
Safeguards in place at Jordan Hoffman Acupuncture include:
- Limited access to facilities where information is stored
- Policies and procedures for handling information
- Requirements for third parties to contractually comply with privacy laws
- All medical files and records are kept on permanent file
In administering your health care, we gather and maintain information that may include non-public personal information
- About your financial transactions with us (billing transactions)
- From your medical history, treatment notes, all test results, and any letters, faxes, emails or telephone conversations to or from other health care practitioners concerning your healthcare
- From healthcare providers, insurance companies, workers’ compensation and your employer, and other third party administrators (e.g. request for medical records, claim payment information)
We here, at Jordan Hoffman Acupuncture, value our relationship with you and respect your privacy. If you have any questions about our privacy guidelines, please call us during regular business hours.
Thank you for placing your trust in us.
By voluntarily signing below, I show that I have reviewed and received a copy of Jordan Hoffman Acupuncture’s HIPP.
Signature of Patient/Representative_____________________________ Date___________