Nephrology & Hypertension Associates of New Jersey
Patient Name:
Emergency Contact:
Under the new HIPPA regulations that went into effect on April 14, 2003, we are only privileged to release health information to family members that you designate us to.
Please check off and provide the names and contact information for the following family members that you would like us to release your health information to.
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.
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.
Family/Personal History:
State of New Jersey mandates that every physician documents and barrier to care including cultural and linguistic needs in the medical record. Factors affecting care are visual or auditory factors which may impede your ability to comprehend medical discussions and language, cultural and/or religious customs which may impact the medical provider’s ability to provide medical care. Addressing these needs will improve patient satisfaction and also decrease health care disparities.
Advance Directives is a federal and state mandates Self-Determination Act enacted in 1990. This allows you to provide specific instructions and directions regarding your own medical care wishes if you become incapacitated. The patient-physician relationship provides a direct opportunity for you to discuss these types of decisions.
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.
I authorize the use and disclosure of the health information for the individual named above as described below.
This information may be disclosed to and used by the following organization:
Organization Name: Nephrology & Hypertension Associates of NJ
Reason / Purpose for the request: Continuity of Care
I understand that the information in my health records may include information relating to the (HIV) Human Immunodeficiency Virus, (AIDS) Acquired Immune Deficiency Syndrome, psychological conditions or treatment, sexually transmitted diseases, drug/alcohol dependence status, detoxification or rehabilitation services.
I understand the authorizing this disclosure of health information is voluntary and I can refuse to sign this form if I do not wish this request to be processed. I do not need to sign to assure treatment. I understand I may inspect or obtain a copy of the information to be used or disclosed as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules.
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.
This notice describes the privacy practices of the Nephrology & Hypertension Associates of New Jersey and that of:
All Nephrology & Hypertension Associates of New Jersey entities, sites, and locations that are subject to HIPPA regulations follow the terms of this notice. In addition, these entities, sites, and locations may share medical information with each other for the treatment, payment or health care operations purposes described in this notice. All of the entities, sites and locations are hereafter referenced as Nephrology & Hypertension Associates for New Jersey.
Nephrology & Hypertension Associates of New Jersey understands that medical information about you and your health is personal and we are committed to protecting it. This notice applies to all records of your care generated by Nephrology & Hypertension Associates of New Jersey. This notice informs you on how Nephrology & Hypertension Associates may use and disclose information about you. It describes your rights and also the obligations Nephrology & Hypertension Associates of New Jersey has regarding the use and disclosure of your information. Nephrology & Hypertension Associates of New Jersey is required by law to do the following:
Nephrology & Hypertension Associates of New Jersey may use or disclose your PHI for three reasons:
Nephrology & Hypertension Associates of New Jersey may use and disclose you PHI without your authorization for the following reasons:
Uses and Disclosures that require you to have the opportunity to agree or object
If you would like additional information about Nephrology & Hypertension Associates of New Jersey privacy practices, if you think that we have violated your privacy rights, or if you disagree with a decision we made about access to your PHI, contact the Chief Privacy Officer, Nephrology & Hypertension Associates of New Jersey, 201 Laurel Oak Road, Suite B, Voorhees, NJ 08043, telephone 856-566-5478. You may also send a written complaint to the Secretary of the Department of Health and Human Services, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington D.C 20201.
Nephrology & Hypertension Associates of New Jersey reserves the right to change the terms of this notice and our privacy policies at any time. Before any important changes, we will promptly change this notice and post a new notice.
This notice went into effect on April 14, 2003 and applies to designated corporate subsidiaries of Nephrology & Hypertension Associates of New Jersey.
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.