Consent to Use and Disclose Protected Health Information
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
Your protected health information will be used by Upper East Orthopaedics, PC or disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice.
THE NOTICE OF PRIVACY PRACTICES
Upper East Orthopaedics, PC is required to provide to you a notice that describes how information about you may be used and disclosed. Additionally, we must provide you information on how you may get access to this information. These policies and practices are defined in the “Notice of Privacy Policies and Practices” provided to you. PLEASE REVIEW IT CAREFULLY.
YOU MAY PLACE RESTRICTIONS ON THE USE OR DISCLOSURE OF YOUR HEALTH INFORMATION
You may request a restriction on the use or disclosure of your protected health information. However, Upper East Orthopaedics, PC may or may not agree to your request to restrict the use or disclosure of your protected health information. You may be asked to complete an authorization to activate this request. Please consult with a practice representative or the Office Manager if you would like additional information or clarification.
It is a violation of the federal privacy standards if Upper East Orthopaedics, PC agrees and fails to comply with your request. The restrictions requested will not affect use and disclosure of your information before the date of your request. If you still have questions after reviewing the Notice of Privacy Policies & Practices, please consult with a practice representative or the Office Manager at the location and contact information listed on the second page of the document.
YOU MAY REVOKE THIS CONSENT AT ANYTIME
You may revoke this consent at anytime; however, Upper East Orthopaedics, PC requires that you must revoke this consent in writing. If you choose to revoke this consent, the revocation will not affect use and disclosure of your information before the date of your request.
CHANGES TO PRIVACY PRACTICES
Upper East Orthopaedics, PC reserves the right to change or modify the privacy practices outlined in the Notice of Privacy Policies & Practices. Upper East Orthopaedics, PC will notify you of any changes of privacy practices either by mail, at your next appointment, or any other pre-approved method that you request.
I have reviewed this consent form, received the “Notice of Privacy Policies and Practices” and give my permission to Upper East Orthopaedics, PC to use and disclose my health information in accordance with this consent and the notice provided.
HIPPA Email Consent
I have been informed by the staff of Upper East Orthopaedics of the following:
• When we send you an email, or you send us an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is transmitted over the Internet. In addition, once the email is received by you, someone may be able to access your email account and read it.
• HIPAA stands for the Health Insurance Portability and Accountability Act. HIPAA was passed by the U.S. government in 1996 in order to establish privacy and security protections for health information. Email is a very popular and convenient way to communicate for a lot of people, so in their latest modification to the HIPAA act, the federal government provided guidance on email and HIPAA. The guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email.
• X-ray films can be alternatively provided on a USB drive which is a secure method.
I understand the risks of unencrypted email and do hereby give permission to Upper East Orthopaedics, PC to send me personal health information (including x-ray films) via unencrypted email.