HIPAA policy

Peninsula Healthcare Connection Providing Healthcare to the Homeless of the Mid-Peninsula

HIPAA Information and Consent Form

There is a law, The Health Insurance Portability and Accountability Act (HIPAA) that protects your privacy. This form is a summary version. A more complete text is available on request in the office. What this is all about: 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 exchange of information necessary to provide you with medical services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

  1. Before we share your health information to anyone, we will obtain your written permission which you can take back at any time.  This means that your health information will be kept confidential except as is needed to provide medical treatment, communicate with your insurance company, to meet legal requirements such as reporting certain diseases to the county health department and complying with a subpoena or to insure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, the county health department for certain conditions, the health insurance company that pays for your care (if you have insurance) and the Courts as law requires. With these exceptions, your records will not be available to anyone other than our office staff in delivering your care.  Anyone with access to your health information must agree to abide by the confidentiality rules of HIPAA.1. Before we share your health information to anyone, we will obtain your written permission which you can take back at any time.  This means that your health information will be kept confidential except as is needed to provide medical treatment, communicate with your insurance company, to meet legal requirements such as reporting certain diseases to the county health department and complying with a subpoena or to insure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, the county health department for certain conditions, the health insurance company that pays for your care (if you have insurance) and the Courts as law requires. With these exceptions, your records will not be available to anyone other than our office staff in delivering your care.  Anyone with access to your health information must agree to abide by the confidentiality rules of HIPAA.
  2. If you have concerns or complaints regarding your privacy, please bring them to the attention of the office manager or the doctor.
  3. We will provide patients with access to their records in accordance with state and federal laws.
  4. You have the right to request restrictions in the transfer of your Protected Health Information (PHI).  You have the right to request changes to the PHI.  You have the right to tell us how you would like to be contacted when confidential information needs to be communicated (telephone, mail etc).  You have a right to receive a report regarding when and why confidential information is shared.

NAME: ______________________________

DATE: ______________________________

Hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this shall remain in force from this time forward.

PDF FORM