HIPAA Compliant Form

As of April 14, 2003 this office is HIPAA Compliant And As of July 27, 2009 this office is Red Flag and Identity Theft Compliant.

I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I
have read (or had the opportunity to read if I so chose) and understood the notice. (Available on website ‘New Patient’ inner page)

I give Dr. Vail’s office permission to call my residence and/or place of business to confirm appointments, or to leave messages to call his office regarding test results.

This notice also gives permission to send health information to insurance companies, family physician, or other specialist(s) that may be involved in your care.

I also acknowledge that I was provided a copy of the Red Flag Rule/Identity Theft Compliance notice and have read (or had the opportunity to read if I so chose) and understood the notice. (Available on website ‘New Patient’ inner page)

I give Dr. Vail’s office permission to copy my driver’s license, insurance card, or any other identification to verify my identity. Under the compliance, I give my permission for Dr. Vail’s office to look into an suspicious activity regarding my account which could
include (but is not limited to) placing a hold on the account, contacting insurance companies, or deferring non-urgent services until the matter is cleared as specified by the compliance program.

We also participate in one or more Health Information Exchanges. Your healthcare providers can use this electronic network to securely provide access to your health records for a better picture of your health needs. We and other healthcare providers, may allow access to your health information through the Health Information Exchange for treatment, payment or other healthcare operations. This is a voluntary agreement. You may opt-out at any time by notifying the office manager.

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

By typing your name and signature above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.