HIPAA Consent

This notice explains how your medical information may be used and disclosed and how you can access this information. In 1996, Congress enacted the Health Insurance Portability and Accountability Act (HIPAA), which establishes federal regulations to protect your privacy by limiting the disclosure of Individually Identifiable Health Information to specific individuals. However, these restrictions do not interfere with the usual exchange of information needed to provide you and your family with effective treatment.

HIPAA grants you certain rights and protections as a patient. We strive to balance these rights with our commitment to delivering high-quality service and care. Please note that this form does not provide a comprehensive overview. A more detailed version is available upon request or at https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations.

Please note the following policies in this agreement:

Health Information Exchange: I authorize the disclosure of my Protected Health Information (PHI) to communicate results and care decisions to my family members and others whom I have selected for this purpose. My personal information will be kept confidential, except when necessary, to manage all administrative matters effectively. This includes sharing information with our healthcare providers, laboratories, hospitals, and insurance companies as required. We utilize electronic medical records, and I agree to the data exchange procedures established by Visalia Family Practice.

I authorize disclosure to all my current and future treating providers participating in the Health Information Exchange. I understand I have the right to receive a list of all such disclosures from the Health Information Exchange.

 Authorization: If I want my personal information shared with specific family members or friends, I must complete authorization to disclose personal health information so that Visalia Family Practice can discuss it openly.

Business Associate Agreements: This practice uses external vendors to conduct our business. These vendors may have access to Protected Health Information (PHI) and must adhere to HIPAA's confidentiality rules.

Medical Records Request: The practice agrees to provide access to Medical records according to State Law

Patient outreach: Our office provides courtesy reminders for upcoming appointments and health outreach to patients. This may be done by calling patients or using other methods.

Outside document review: The patient acknowledges and agrees to government agencies or insurance companies inspecting the office and reviewing documents, which may include PHI, as part of their regular duties.

Privacy Officer: The patient agrees to report any privacy concerns or complaints to the Privacy Officer, whose contact information is displayed in the Office Waiting Room.

I understand that I may be denied services if I refuse to consent to disclosure for treatment, payment, or healthcare operations if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.

I acknowledge that I can revoke this authorization at any time, except when action has already been taken based on it. Unless I revoke my consent earlier, this consent and agreement will remain in effect indefinitely.