HIPAA Policy

Health Insurance Portability and Accountability Act

The Department of Health and Human Services has established a “Privacy Rule” to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients’ consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.

As our patient, or the parent/guardian of our patient, we want you to know that we respect the privacy of your/your child’s personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect our patients’ privacy. When it is appropriate and necessary, we provide the minimum information necessary to only employees of Project CHILLD, when we feel they are in need of your/your child’s health care information and information about treatment, payment or health care operations, in order to provide health care that is in our patient’s best interest. We also want you to know that we support your full access to your/your child’s personal medical records.

You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you/your child should you choose to refuse to disclose your/your child’s Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent.

If you have any objections to this form, please ask to speak with someone in our office.

You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.