In response to the misuse of Personal Health Information (PHI), the department of Health and Human Services has established a “Privacy Rule” to help ensure that PHI is kept Private. This rule was also established in order to provide a standard for health care operation.


We want you to know that we respect the privacy of your medical records and will take all reasonable measures to secure and protect your privacy. When necessary, we will provide the minimum necessary information to only those we feel are in need of your PHI in order to provide health care that is in your best interest.


We support your full access to your personal medical records. You should be aware that we have indirect treatment relationships with you that include but not limited to laboratories, pharmacies and other medical offices. As such, we may need to discuss PHI for purposes of treatment, payment and/or other health care operations. These outside entities do not necessarily need to obtain your consent for these communications.


You have the right to refuse to consent to the use or disclosure of your PHI. This refusal must be in writing. Under the HIPAA law, we have the right to refuse to treat you if you choose to refuse disclosure of your PHI. If you give consent to disclose your PHI, by signing this document, you can at some future time request to refuse future disclosures of your PHI. This refusal must be in writing. However, you may not revoke actions that have already been taken, which relied on this or a previously signed consent.


You may receive a copy of our Patient Privacy Policy. You have the right to review our privacy notice, request restrictions and revoke consent in writing after you have reviewed our privacy notice.


Please speak with our Compliance Office if you have any objections to this consent.