Notice of Privacy, p 4 of 4
CHANGES TO THIS NOTICE
We reserve the right to change this notice, and to make the revised or changed
notice effective for medical information we already have about you as well as
any information we receive in the future. We will post the current notice in
the office with its effective date in the top right hand corner
(of page one.) You are entitled to a copy of the notice currently in effect.
If you believe your privacy rights have been violated, you may file a
complaint with our office or with the Secretary of the Department of Health
and Human Services. To file a complaint with our office, contact Dian Payant,
Privacy Officer. You will not be penalized for filing a complaint.
ACKNOWLEDGMENT AND CONSENT
I understand that Pendleton Internal Medicine Specialists (referred to below as "The Practice")
will use and disclose personal health information about me.
I understand that my personal health information may include information both
created and received by the practice, may be in the form of written or electronic
records or spoken words, and may include information about my health history,
health status, symptoms, examinations, test results, diagnosis, treatments,
procedures, prescriptions, and similar types of health-related information.
I understand and agree that Pendleton Internal Medicine may use and disclose my
personal health information in order to:
I also understand that I have the right to receive and review a written
description of how This Practice will handle personal health information about me.
This written description is known as a Notice of Privacy Practices and describes
the uses and disclosures of personal health information made and the information
practices followed by the employees, staff and other personnel of Pendleton
Internal Medicine, and my rights regarding my personal health information.
- Make decisions about and plan for my care and treatment.
- Refer to, consult with, coordinate among, and manage along with other health
care providers for my care and treatment.
- Determine my eligibility for health plan or insurance coverage, and submit bills,
claims and other related information to insurance companies or others who may
be responsible to pay for some or all of my health care; and
- Perform various office, administrative, business functions that support my
physician's efforts to provide me with, arrange and be reimbursed for quality,
cost-effective health care.
I understand that the Notice of Privacy Practices may be revised from time to time, and
that I am entitled to receive a copy of any revised Notice of Privacy Practices.
I also understand that a copy or a summary of the most current version of This
Practice's Notice of Privacy Practices in effect will be posted in waiting/reception area
and is available on the website at pendleton-internal-med.com.
I understand that I have the right to ask that some or all of my health information
not be used or disclosed in the manner described in the notice of Privacy Practices,
and I understand that This Practice is not required by law to agree to such requests.
By signing below, I agree that I have reviewed and understand the information above and
that I have received a copy of the Notice of Privacy Practices.
Description of Representative's Authority