HIPAA Consent Form

You have the right and choice to tell New Orleans Podiatry Associates hereafter referred to as “NOPA” to share information with your family, close friends, or others involved in payment for your case and/or to share information in a disaster relief situation

• We will never share your information for marketing purposes or sales unless you give us written permission.
• You may request that we contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will consider all reasonable requests and must comply if you tell us you would be in danger if we do not.
• You may request to see or obtain a copy of your health and claims records and other patient information. We will provide a copy or a summary of your health and claims records, usually within 30days of your request. We may charge a reasonable fee. You have a right to gain access to our online portal for all health and claims records. Please ask us how if you are interested.
• You may request that we not use or share certain health information for treatment, payment, or our operations. However, we are not required to comply with this request and may deny it if it would affect your care.
• You may request a report detailing the times we have shared your health information, up to six years prior to the desired date, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one report for free within a 12 month period. For any additional accounting within a 12 month period there will be a reasonable fee.
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has the authority and can act for you before we take any action.
• You may complain if you feel we have violated your rights by contacting us using the information on the back page. You may file a complaint with the U.S. Department of Health and Human ServicesOffice for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
• You can ask us to correct your health and claims records if you think they are incorrect or incomplete. We may deny your request, but we will send you a written explanation within 60 days.
• We must follow the duties and privacy practices described in this notice. You may request for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
• We are required by law to maintain the privacy and security of your protected health information. We Dr. Edward Lang Surgery of the Foot and Ankle will notify you promptly if a breach occurs that may have compromised the privacy or security of your information. We will not use or share your information other than as described below unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. For more information visit www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

NOPA can share your health information in the following circumstances:

• with organ procurement organizations
• with a coroner, medical examiner, or funeral director when an individual dies
• for workers' compensation claims
• for law enforcement purposes or with a law enforcement official
• for special government functions such as military, national security, and presidential protective services
• in response to a court or administrative order, or in response to a subpoena
  for public health reasons:
  • preventing disease; helping with product recalls; reporting adverse reactions to medications;reporting suspected abuse, neglect, or domestic violence; preventing or reducing a serious threat toanyone's health or safety

• for health research
• if state or federals laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law
• with other medical professionals who are treating you
• with our recovery agency to collect any outstanding debt
• We can discuss your diagnosis and treatment plan for purposes of obtaining insurance information or reimbursement

Changes to the Terms of This Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.

I acknowledge by my signature that I have read both pages of this Consent for Purposes of Treatment, Payment, Healthcare Operations, and HIPAA, and I have been given a copy for my personal use.

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.