Our Privacy Pledge
We are very concerned with protecting your privacy. While the law requires us to give you this
disclosure, please understand that we have, and always will, respect the privacy of your health
information.
There are several circumstances in which we may have to use or disclose your healthcare information
- We may have to disclose your health information to another healthcare provider or a hospital if
it is necessary to refer you to them for the diagnosis, assessment, or treatment of your health
condition. - We may have to disclose your health information and billing records to another party if they are
potentially responsible for the payment of your services. - We may need to use your health information within our practice for quality control or other
operational purposes
We have a more complete notice that provides a detailed description of how your health information
may be used or disclosed. You have the right to review that notice before you sign this consent form.
We reserve the right to change our privacy practices as described in that notice. If we make a change to
our privacy practices, we will notify you in writing when you come in for treatment or by mail. Please
feel free to call us at any time for a copy of our privacy notices.
*Your right to limit uses or disclosures*
You have the right to request that we do not disclose your health information to specific individuals,
companies, or organizations. If you would like to place any restrictions on the use or disclosure of your
health information, please let us know in writing. We are not required to agree to your restrictions.
However, if we agree with your restrictions, the restriction is binding on us.
*Your right to revoke your authorization*
You may revoke your consent to us at any time; however, your revocation must be in writing. We will
not be able to honor your revocation request if we have already released your health information before
we receive your request to revoke your authorization. If you were required to give your authorization as
a condition of obtaining insurance, the insurance company may have a right to your health information
if they decide to contest any of your claims.