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IMPAC Health
NOTICE OF PRIVACY PRACTICES
IMPAC
Health is required, by law, to maintain the privacy
and confidentiality of your protected health
information and to provide our patients with notice
of our legal duties and privacy practices with
respect to your protected health information.
Protecting the privacy of your personal health
information is important to us. This notice describes
how information about you may be used and disclosed and
how you can get access to this information. Please
review it carefully.
Disclosure of your protected health information without
authorization is strictly limited to defined situations
that include emergency care, quality assurance
activities, public health, research, and law enforcement
activities. Any other disclosures for the purposes of
treatment, payment, or practice operations will be made
only after obtaining your consent. You may request
restrictions on disclosures.
Disclosures of protected health information are limited
to the minimum necessary for the purpose of the
disclosure. This provision does not apply to the
transfer of medical records for treatment.
You may inspect and receive
copies of your records within 30 days of receiving a
request to do so. There may be a reasonable cost-based
fee for photocopying, postage and preparation.
You may
request changes of your records. Our practice has the
right to accept or deny your request.
We
maintain a history of protected health information
disclosures that is accessible to you.
In the
future, we may contact you for appointment reminders,
announcements, and promotional events and to inform you
about our practice and its staff.
Our
practice is required to abide by this notice. We have
the right to change the notice in the future. Any
revisions will be prominently displayed in a clearly
visible location in our office.
You may
file a complaint about privacy violations by contacting
Dr. Delene Bivolcic.
I have
read the Privacy Notice and understand my rights
contained in the notice.
By way
of my signature, I provide IMPAC Health with my
authorization and consent to use and disclose my
protected health care information for the purposes of
treatment, payment and health care operations as
described in the Privacy Notice.
 Patient’s
Name (print)
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