HIPAA Privacy Agreement

Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))

I understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as:

• a basis for planning my care and treatment;
• a means of communication among the health professionals who may contribute to my healthcare;
• a source of information for applying my diagnosis and surgical information to my bill;
• a means by which a third-party payer can verify that services billed were actually provided;
• a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.
• a record that may include the use of automated technologies or artificial intelligence (AI) to assist my provider in clinical documentation, analysis of skin conditions, or mole-mapping, with the understanding that all final medical decisions are made by my healthcare provider.

I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this facility’s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.

HIPAA PRIVACY RULE OF PATIENT CONSENT AGREEMENT
Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))

I understand that:
• I have the right to review this facility’s Notice of Privacy Practices at any time;
• This facility has a website and the Notice of Privacy Practices is prominently posted on the website with no download required, but also can be downloaded by PDF if desired. The Notice of Privacy Practices is separate and distinct from the website’s Privacy Policy and copies of the Notice of Privacy Policy are posted in the waiting room lobby and are available at the front desk.
• This facility, reserves the right to change the notice and practices and that prior to implementation will mail a copy of any revised notice to the address I’ve provided if requested;
• I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that this facility is not required by law to agree to the restrictions requested.
• I may revoke this consent in writing at any time, except to the extent that this facility, has already taken action in reliance thereon.
• It is this facility’s procedure to share Protected Health Information with labs, x-rays, consulting physicians, and hospitals as necessary to provide your healthcare. We will call the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary Protected Health Information for each transaction.