Patient HIPAA Acknowledgement & Designation Disclosure Form

HIPAA Notice of Privacy Practices and Consent to Use or Disclose Information for Treatment, Payment, or Health Care Operations

Effective Date: 11/06/2024

1. Introduction

This notice describes how your medical information may be used and disclosed by Neurovations Neurology Clinic and how you can access this information. We are committed to protecting your health information and adhering to legal and ethical standards.

2. Your Health Information Rights

You have the right to:

Inspect and Copy: Access your medical records to inspect and obtain copies, as allowed by law.
Request Restrictions: Ask for limits on certain uses or disclosures of your information. While we are not always required to agree, we will consider your request.
Confidential Communications: Request that we communicate with you through specific methods or locations.
Amend Information: Request amendments to your records if you believe they are incorrect or incomplete.
Receive an Accounting of Disclosures: Obtain a list of disclosures made for purposes other than treatment, payment, and healthcare operations.
Receive a Paper Copy of This Notice: You may request a paper copy of this notice at any time.

3. Our Responsibilities

Neurovations Neurology Clinic is required by law to:

Maintain the privacy of your health information.
Provide you with this notice of our legal duties and privacy practices.
Follow the terms of this notice currently in effect.

4. How We May Use and Disclose Health Information

Your health information may be used or disclosed for the following purposes:

Treatment: We may use your health information to provide you with medical treatment or services. We may share information with doctors, nurses, technicians, and other personnel involved in your care.
Payment: Your health information may be used to bill and collect payment from you, your insurance company, or a third party.
Health Care Operations: We may use or disclose your health information to support our healthcare operations, which include staff training, quality assessment, and compliance reviews.

5. Special Protections for Certain Health Information

Certain health information, including HIV status, mental health records, substance use information, and genetic testing results, is subject to special protections under federal and state law. Neurovations Neurology Clinic will not disclose this information without specific consent, except as required or permitted by law.

6. Other Permitted Uses and Disclosures

We may also use or disclose your health information in certain situations without your consent, as permitted or required by law, such as:

Public Health and Safety Risks
Law Enforcement
Research (under specific conditions)
Workers’ Compensation
To Avert a Serious Threat to Health or Safety

7. Written Authorization for Other Uses

Any uses and disclosures not described in this notice will require your written authorization. You may revoke your authorization at any time in writing, except to the extent that we have already acted based on your authorization.

Consent to Use or Disclose Information for Treatment, Payment, or Health Care Operations

By signing below, I consent to the use and disclosure of my health information by Neurovations Neurology Clinic as outlined in this notice. I understand that this consent allows my health information to be used for purposes of treatment, payment, and healthcare operations as described.

Name of Patient

Signature of Patient

Date

Designation of Certain Relatives, Close Friends, and other Caregivers as my Personal Representative

I agree that the practice may disclose certain of my health information to a Personal Representative of my choosing, since such person is involved with my health care or payment relating to my health care. In this case, the Physician Practice will disclose only information that is directly relevant to the person’s involvement with my health care or payment relating to my health care.

Print Name

Date of Birth

Phone

Print Name

Date of Birth

Phone

Print Name

Date of Birth

Phone

acting on behalf of my minor son/daughter

Parent/Guardian

Name of Patient

As legal Personal Representative in all matters. If the representative is a court-appointed legal guardian, a copy of court documents must be provided and kept in medical records.

Request to Receive Confidential Communications by Alternative Means

I understand that as part of my health care and treatment, Neurovations Clinic may need to reach me by phone. As provided by Privacy Rule Section 164.522(b),

I DO hereby authorize and request that the Practice make all communications to me by the alternative means that I have listed below regarding instructions, procedures, clinical test results, billing and/or appointment needs, etc.

Home/Cell Telephone Number

Preference for leaving messages

Leave a voicemail with detailed information

E-mail to address listed information

I DO NOT authorize Neurovations Clinic to contact me to leave a message on my home or cell phone regarding communication of my health care/treatment such as instructions for procedures, clinical test results, billing and/or appointment needs, etc. I understand that by selecting this option it may result in delayed communication of pertinent treatment information such as medication changes, appointment confirmations, billing communications or clinical call backs. I understand that I will be responsible for making appointments to obtain this information. If you have any questions regarding this notice or any of our office policies, please contact the Practice Administrator at 321-285-2369 Thank you.