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:
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: The patient’s school (for the release of proof of immunization) and insurance company are already included in this HIPAA Authorization. If you authorize any additional individuals, such as parent(s) / guardian(s), or any additional facilities to have access to your protected health information, please list their information below.
Your information will be encrypted.
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