Privacy Notice (HIPPA)

Baker Chiropractic & Acupuncture

The Health Insurance Portibilty Accountablity Act of 1996 (HIPAA)

 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  Please review it carefully.

 A signed consent form permits us to use your personal health information within our office for the purposes of treatment, receiving payment, and health care operations of our practice. 
 It is the policy of this practice to release only the minimum necessary information to any source not directly linked to hands on care and treatment of patients in our office as outlined in the Health Insurance Portability Accountability Act of 1996 (HIPAA).
 This includes third party payers, insurance companies, etc. In these cases your signed consent form permits us to release only enough information to complete the insurance claim process.
 In some cases, patients may wish to have their protected health information released.  In those cases if the outside entity can provide us with a copy of a medical records release form signed by the patient then we will comply while still providing only the minimum necessary information, or the amount of information requested by the patient.
 In cases of public health, HIPAA does not protect some information.  Where we are required by law to release information to any law enforcement or public health agency, our office will only release the minimum information required by law to any outside entity.  In all cases we will follow the most restrictive laws, state or federal, that apply in protecting your medical information. 
 You, as a patient have a right to see your medical record during normal office hours.
ADDITIONAL USES OF YOUR HEALTH INFORMATION
 Our staff may use your health information to remind you of appointments, send birthday or seasonal greeting cards, mailings, newsletters, information about our practice or other information we feel you may be interested in or may improve your health.  We will not release a mailing list to any outside entity for solicitation of business not related to our office

Baker Chiropractic & Acupuncture

Authorization to Disclose Protected Health Information

 The Health Insurance Portability Accountability Act of 1996 (HIPAA) requires that we receive your permission before we use the personal information in your medical records for any reason.
 This consent form gives Baker Chiropractic & Acupuncture permission to use your Protected Health Information (PHI) to carry out treatment, receive and/or as part of health care operations of our practice.
 HIPAA also requires us to have a written notice of our privacy policy describing how medical information about you may be used and disclosed. If you so desire, this written notice is available at the front desk for you to read during normal business hours.
 You have the right to revoke, in writing, this consent form at any time, although any services performed prior to the revocation of this consent are covered by this consent.

Patient Signature: ___________________________Date:_____________

Restrictions:

Right to Revise Privacy Practices: As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our office’s polices and practices may be required by changes in federal and state laws and regulations. Upon receipt, we will provide you with the most recent notice on an office visit. The revised policies and practices will be applied to all protected health information we maintain.

Doctor/Staff Signature: _________________________ Date: __________