CHICAGO IV SOLUTION
HIPAA INFORMATION AND CONSENT FORM

The Health Insurance Portability and Accountability Act (HIPAA) provide safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to proVide you with office services. HIPAA provides certain rights and protections to you as a patient. Additional information is available from the United States Department of Health and Human Services at www.his.Nov.

WE HAVE ADOPTED THE FOLLOWING POLICIES:

• 1. Patient information will be kept confidential EXCEPT as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open rack files and will not contain any coding that identifies a patient’s condition or information that is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient’s records, PHI and other documents or information.
• 2. We utilize a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
• 3 You understand and agree to inspections of the office and review of documents that may include PHI by governmental agencies or insurance payers in normal performance of their duties.
• 4. You agree to bring any concerns or complaints regarding privacy to the attention of our office manager or physician.
• 5. We agree to provide patients with access to their records in accordance with state and federal laws.
• 6. We may change, add, delete or modify any of these provisions to better serve the needs of both the practice and the patient.
• 7. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

• • I do hereby consent and acknowledge my agreement to the terms set forth in CHICAGO IV SOLUTION’S HIPAA INFORMATION AND CONSENT FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

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