Client Intake Form

The Health Insurance Portability and Accountability Act (HIPAA) is in place to ensure the protection of your privacy. The enforcement of HIPAA requirements officially commenced on April 14, 2003. Many of these guidelines have already been an integral part of our practices for a considerable period. The document you are currently reviewing is a simplified version. For a more comprehensive text, a complete version is accessible within our office. The primary focus of this document revolves around regulations and limitations concerning access to or disclosure of your Protected Health Information (PHI). These limitations do not impede the normal exchange of information necessary for providing you with our office services. HIPAA extends specific rights and safeguards to you as a patient. We carefully balance these provisions with our commitment to delivering high-quality professional care and service. For additional information, you can refer to the U.S. Department of Health and Human Services at www.hhs.gov. We have adopted the ensuing policies: Your patient information will be maintained as confidential, except when necessary to offer services or manage administrative matters pertinent to your care. This includes sharing information with other healthcare providers, labs, and health insurance entities, as required for your treatment. Patient records might be stored openly but without identifiers for your condition or non-public data. During the process of care, records might be temporarily placed in administrative areas like the front office or examination room, accessible only to our staff. You hereby consent to the routine procedures within our office for handling charts, patient records, PHI, and other documents or information. Our policy involves reminding patients about their appointments, which we might do through telephone, email, U.S. mail, or any suitable means as per your preference. We may also communicate changes in office policy and beneficial technological advancements. The practice collaborates with several vendors for business operations. These vendors may access PHI but are bound by HIPAA's confidentiality regulations. You acknowledge and consent to governmental agencies or insurance providers conducting inspections of the office and reviewing documents, which could include PHI, as part of their standard duties. Any concerns or complaints about privacy matters should be brought to the attention of the office manager or the doctor. Your confidential information will not be exploited for marketing or advertising purposes related to products, goods, or services. We commit to granting patients access to their records in accordance with state and federal laws. These provisions may be subject to changes, additions, deletions, or modifications to better suit the practice and patient needs. You possess the right to request restrictions on the use of your protected health information and to suggest alterations to specific office policies governing your PHI. However, we are not obligated to adjust internal policies to align with your requests. By agreeing to the HIPAA Information Form's terms and any subsequent policy changes, I confirm my consent and understanding of these terms, effective from this point onward.