Notice of Privacy, p 4 of 4

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.



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:

  • 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 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.

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

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.

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  (Patient representative)   
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