Our practice is committed to educating our patients about healthcare issues that affect them. As a result, we are providing you with general information about Privacy Rule, a federal regulation of the Health Insurance Portability and Accountability Act of 1996 (HIPPA) along with brief overview of our Notice of Privacy. Our practice is complying with HIPPA’s regulations.

When the Health Insurance Portability and Accountability Act (HIPPA) was passed in August of 1996, this gave the federal government the ability to mandate how healthcare plans, providers, and clearinghouses store and send a patient’s personal information as it relates to healthcare. The privacy rule was created to protect your rights as a patient of our practice, and we are required by law to be compliant with this regulation. Under the Privacy Rule you are guaranteed access to your medical records, allowed control over how your protected health information is used and disclosed and allowed to take action if your privacy is compromised by following the practice’s policy. Our practice is dedicated to maintaining the privacy of your personal information.

Any health information you provide our practice, including your mailing address. IIHI is any information that is created and retained by our practice or received by another healthcare provider that relates to treatment, payment, and/or that identifies you as an induvial.

Any health information you provide our practice, including your mailing address. IIHI is any information that is created and retained by our practice or received by another healthcare provider that relates to treatment, payment, and/or that identifies you as an induvial.

Our practice has an official Notice of Privacy Practice posted in our waiting room informing our patients about their rights surrounding the protection of your IIHI and our obligations concerning the use and disclosure of your IIHI. This notice applies to all records created or retained by our practice. We can update our Notice of Privacy Practices at any time. It will be posted, and a copy is provided in our waiting room and you can take a copy of the current notice at any time.

Any health information you provide our practice, including your mailing address. IIHI is any information that is created and retained by our practice or received by another healthcare provider that relates to treatment, payment, and/or that identifies you as an induvial.

Our practice has an official Notice of Privacy Practice posted in our waiting room informing our patients about their rights surrounding the protection of your IIHI and our obligations concerning the use and disclosure of your IIHI. This notice applies to all records created or retained by our practice. We can update our Notice of Privacy Practices at any time. It will be posted, and a copy is provided in our waiting room and you can take a copy of the current notice at any time. The following categories describe the different ways in which we may use and disclose your IIHI:

What have rights regarding the IIHI that we maintain with you. In our Notice of Privacy, you can view the policies and procedures you will need to follow for the areas listed below. 1.Confidential Communications 2.Requesting Restrictions 3.Inspection and Copies 4.Amendment 5.Accounting of Disclosures 6.Right to a Paper Copy of this Notice 7.Right to file a complaint 8.Right to provide and Authorization for other uses and disclosures If you have any questions about this notice, please ask the receptionist to speak to our Privacy Officer.

I have read the short notice provided by East Florida Premium Medical Care and have been informed of how to obtain more information regarding our Notice of Privacy.

• I understand that my health care and the payment for may health care will no be affected if I do not sign this form.
• I understand that I may see and copy the information described on this form if I ask for it, and that I et a copy of this form after I sigh it.
• Further, I understand there may be a fee for a copy of this information
.

• I understand that I may revoke this authorization at any time by notifying the providing organization in writing, but if I do it won’t have any affect on any actions they took before they received the revocation.
• I understand that my records are protected under state and federal law. I understand that specific information to be disclosed may include history of drug or alcohol abuse, mental health treatment, AIDS or any other medical information.