HIPAA Forms


Patient Rights regarding Medical Records and Responsibilities as required by the Health Insurance Portability and Accountability Act (HIPAA)

All requests to inspect, copy, amend, restrict, or share health information must be made in writing on the proper forms, which will provided upon request.  All changes to preferred forms of communication must also be made in writing.

You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy:  You have the right to inspect and copy health information that may be used to make decisions about your care. Usually, this includes health and billing records.

If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies and services associated with your request.

We may deny your request to inspect and copy in certain, very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. This review will be conducted by another licensed health care professional chosen by our practice. The person conducting the review will not be the person who denied your request. This practice will comply with the outcome of the review.

Right to Amend: If you believe that health information we have about you is incorrect or incomplete, you may ask us to amend the information.

We may deny your request for an amendment if it is not in writing or does not include a reason for the following:  The health information was not created by us, unless the person or entity that created the information is no longer available to make the amendment and is not part of the health information kept by or for our practice and is not part of the information that you would be permitted to inspect and the copy is accurate and complete.

Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.

Right to an Accounting Disclosure:  You have the right to request a list of the disclosures of your health information we have made, except for uses and disclosures for treatment, payment, and health care operations, as previously described.

Right to Request Restrictions:  You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively affect the care we provide you.

Right to Request Confidential Communications: You have the right to request that we communicate with you about health matters in a certain way or at a certain location.

Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this notice at any time. To obtain a copy please request it from any staff member.

Changes to This Notice: We reserve the right to change this notice and apply it to any part present, or future health information we have about you. We will post a copy of the most current notice in our facility with the effective date on the first page. You may request a copy you may request at copy at anytime.

If you believe your Privacy Rights have been violated, you may file a complaint with us or with the Secretary of The Department of Health and Human Services. Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. YOU have the right to revoke this permission for any health information that has not yet been shared

Click here for the Health and Human Services Website (www.HHS.gov) for more information.


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Our clinic offers exceptional care for the entire family. The clinic is open to the public and accepts most types of insurance. New patients are always welcome!