Notice of Privacy Practices
Patients should review the document below for information on how the provider uses and discloses their personal, health, and financial information. These documents also outline the various privacy rights available to patients.
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Individual Rights Forms
The following is a brief description of the various individual rights and the appropriate form to invoke one of these rights.
Authorization for Release of PHI
This form requests an inspection or copy of protected health information about a patient. This form was last updated in July 2020.
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Accounting of Disclosures
This form requests a list of disclosures made of a patient’s protected health information. Disclosures made for payment and health plan operations are excluded from this process. The form was last updated in July 2020.
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Amend
This form requests a correction to provider-created protected health information that a patient feels is inaccurate or incomplete. This form was last updated in June 2016.
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Complaint
This form documents an issue or concern if a patient believes his or her privacy rights may have been violated. This form was last updated in in July 2020.
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Confidential Handling
This form requests that the provider communicate with a member about protected health information in a different way during life-threatening situations. Examples of alternate means could include telephone, mail, e-mail, or different address. The form was last updated in in July 2020.
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Restriction & Termination of Restriction
This form requests or terminates limitations or restrictions of disclosures of a patient’s protected health information to others such as a family member, friend, spouse, doctor, or any other party. This form was last updated in in July 2020.
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Patient Consent for Representation
This form grants the provider permission to share your information to a trusted individual(s) that you choose. The form below allows you to choose the level of information to share with the trusted individual. You can specify any and all information, information specific to a treatment or injury, or something different. This form was last updated in in June 2016.
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Information regarding Advanced Directives
This document provides the patient with information regarding an advance directive regarding medical treatment when they are unable to make their wishes know because of illness or injury.
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