Authorization to use or Disclose Medical Records

Please correct the errors described below.

I give authorization to the provider listed below to disclose a copy of the specific health/medical information identified below.

TO: (Name, Address, Phone of Recipient of Records)

HAKSHA HEALTHCARE S.C. PHONE: 262-439-9544 FAX: 262439-8933

RECORDS FROM (Who is Releasing the Records):

For the Following Purposes

By Checking the Boxes Below, I Specifically Authorize the Use and/or Disclosure of the Following Health Information and/or Medical Records, If Such Information and/or Records Exist:

The Following Items Must Be Initialed to Be Included in the Use And/or Disclosure:

I understand that, if the person or entity receiving the information is not a health care provider or health plan covered by federal privacy regulations in accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the information described above may be re-disclosed and no longer protected by HIPAA and other federal and state regulations. However, the recipient may be prohibited from redisclosing HIIV-related, alcohol or drug treatment without my authorization unless permitted to do so under federal or state law. I understand I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights.

I also understand that the person I am authorizing to use and/or disclose the information may not receive compensation for doing so and this authorization does not authorize you to discuss my health information or medical care with anyone other than the entity, attorney or governmental agency specified in items above.

I further understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment of my eligibility for benefits. I may inspect or copy any information to be used and/or disclosed under this authorization.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.


The Health Insurance Portability and Accountability Act of 1996 (HIPAA) restricts the use or disclosure of protected health information (PHI) other than treatment, payment or healthcare operations (TPO). Others that are permitted to receive disclosure re of information by law include: Judicial proceedings, coroners, medical examiners, research purposes, law enforcement, worker’s compensation and other areas so designated by law.

Release or disclosure of information to family members, friends, clergy or others involved in a patient’s care is NOT included in the General Rule and require specific authorization for disclosure of information.

If you would like us to share your PHI with family members or others, please fill in the information below for each individual, designate if unrestricted or limited release of information and date and initial each authorization. Please note that ABSOLUTELY NO INFORMATION WILL BE DISCLOSED to spouses, children, other family members, care givers or friends if not authorized below. You may rescind or change any authorization by a written request at any time.

1. Please list the family members or other person(s), if any, whom we may inform about your general medical condition and your diagnosis, records, reports (including treatment, payment and health care operations):

Add Additional Name

2. Please list the family members or others, if any, whom we may inform about your medical condition ONLY IN AN EMERGENCY.

Add Additional Name

4. Print the telephone number or email address where you want to receive calls about your appointments, lab and x-ray results or other health care information if other than your home.

I understand the Privacy Protection Act and have been offered a copy of the Notice of Privacy Policies and do hereby authorize Haksha Healthcare S.C. to disclose as I have identified above.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.


Effective Date: March 26, 2013


This Notice is provided to you pursuant to the Health Insurance Portability and Accessibility Act of 1996 and its implementation regulations (“HIPAA”). It is designed to tell you how we may, under federal law, use or disclose your Health Information. It has been updated to the HITECH Omnibus Rule requirements.

I. Your Rights.

You have the right to request restrictions on the uses and disclosures of your Health Information. However, we are not required to comply with all requests. You are allowed to restrict transmittal of health care charges to your insurance carrier if you pay for those services, in full, by other means. You have the right to receive your Health Information through confidential means and in a manner that is reasonably convenient for you and us.

You have the right to inspect and copy your Health Information. You may request your records in digital format and have your records sent digitally to another provider with written authorization. You have a right to request that we amend your Health Information that is incorrect or incomplete. We are not required to change your Health Information and will provide you with information about our denial and how you can disagree with the denial.

You have a right to receive an accounting of disclosures of your Health Information made by us, except that we do not have to account for disclosures: authorized by you; made for treatment, payment, health care operations; provided to you; provided in response to an Authorization; made in order to notify and communicate with approved family members; and/or for certain government functions, to name a few. You have been provided with a paper copy of this Notice of Privacy Practices. If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, please contact our HIPAA Compliance Officer at our clinic.

II. We May Use or Disclose Your Health Information for Purposes of Treatment, Payment or Healthcare Operations without Obtaining Your Prior Authorization and Here is One Example of Each:

We may provide your Health Information to other health care professionals including doctors, nurses and technicians for purposes of providing you with care. Our billing department may access your information and send relevant parts to insurance companies to allow us to be paid for the services we render to you. We may access or send your information to our attorneys or accountants in the event we need the information in order to address one of our own business functions. Our attorneys and accountants are required to maintain confidentiality when they receive patient information.

III. We May Also Use or Disclose Your Health Information Under Certain Circumstances without Obtaining Your Prior Authorization.

However, in general, we will attempt to ensure that you have been made aware of the use or disclosure of your Health Information prior to providing it to another person. Some instances where we may need to disclose information include but are not limited to:

To Notify and/or Communicate with Your Family. We will only communicate with family members that we are authorized to communicate with based on your completion of the Authorization to Disclose Health Information to Family and Friends form.

As Required By Law. For Health Oversight Activities. We may use or disclose your Health Information to health oversight agencies during the course of audits, investigations, certification and other proceedings.

In Response to Civil Subpoenas or for Judicial Administrative Proceedings. We may use or disclose your Health Information, as directed, in the course of any civil administrative or judicial proceeding.

To Law Enforcement Personnel. We may use or disclose your Health Information to a law enforcement official to comply with a court order or grand jury subpoena and other law enforcement purposes.

For Purposes of Organ Donation. We may use or disclose your Health Information for purposes of communicating to organizations involved in procuring, banking or transplanting organs and tissues. For Worker’s Compensation. We may use or disclose your Health Information as necessary to comply with worker’s compensation laws.

IV. For All Other Circumstances, We May Only Use or Disclose Your Health Information After You Have Signed an Authorization. If you authorize us to use or disclose your Health Information for another purpose, you may revoke your authorization in writing at anytime. Fundraising. Should our practice use patient information for fund raising we will inform individuals that they have the right to opt out of fundraising solicitations and explain that process. You do have the capability to opt back in should with written notice.

  • Marketing. Should our practice use patient information for marketing purposes we will first obtain your written authorization and fully explain the uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI require will require a separate written authorization.
  • Use or Disclosure of Psychotherapy Notes. Written authorization is required if our practice intends to use or disclose psychotherapy notes.
  • Breach Notice. All patients will be informed if there is a breach, as defined by federal rules, of their unsecured protected health information as required by the HIPAA regulations. Right to Request Restrictions for Disclosures Related to SelfPayment. Our practice is required to comply with a request not to disclose health information to a health plan for treatment when the individual has paid in full out-of-pocket for a health care item or service and signed our “Do Not File Insurance Form”.

V. You Should Be Advised that We May Also Use or Disclose Your Health Information for the Following Purposes: Appointment Reminders. We may use your Health Information in order to contact you to provide appointment reminders or to give information about other treatments or health-related benefits and services that may be of interest to you. Change of Ownership. In the event that our Business is sold or merged with another organization, your Health Information/record will become the property of the new owner.

VI. Our Duties. We are required by law to maintain the privacy of your Health Information and to provide you with a copy of this Notice. We are also required to abide by the terms of this Notice. We reserve the right to amend this Notice at any time in the future and to make the new Notice provisions applicable to all your Health Information — even if it was created prior to the change in the Notice. If any such amendment is made that materially changes this Notice, we will send you another copy

VII. Complaints to our Practice and the Government. You may make complaints to our HIPAA Privacy Officer or the Security of the Department of Health and Human Services (“DHHS”) if you believe your rights have been violated. We will review all complaints in a professional manner and keep you informed of your rights as our patient. We promise not to retaliate against you for any complaint you make about our privacy practices.

VIII. Contact Information. You may contact us about our privacy practices or file a complaint by calling our Privacy Officer at our office number located at top of the form.

You may contact the DHHS at: The U.S. Department of Health and Human Services, 200 Independence Avenue, S. W., Washington, D.C. 20201, Telephone: 202-619-0257, Toll Free: 1-877-696-6775


*You May Refuse To Sign This Acknowledgement

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.