HIPAA Notice of Privacy Practices, & Release of Medical Information
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HIPAA Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our notice before signing this consent. The terms of our notice may change. If we change our notice, you may obtain a revised copy by contacting our office or viewing it at www.dupagepediatrics.com.
You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement
By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent. Our practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The patient understands that:
Protected health information may be disclosed or used for treatment, payment, or health care operations
The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice
Our practice reserves the right to change the Notice of Privacy Practices
The patient has the right to restrict the uses of their information but our practice does not have to agree to those restrictions
The patient may revoke this consent in writing at any time and all future disclosures will then cease
Our practice may condition receipt of treatment upon the execution of this consent
All telephone numbers and email addresses provided may be used by the Practice and those acting on its behalf to communicate with the patient by telephone (including cell phone), text or any automated or prerecorded messages.
APPROVAL TO RELEASE IMMUNIZATION INFORMATION I give my permission to disclose/release proof of immunization to the school attended by this patient.
RELEASE OF MEDICAL INFORMATION
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