This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Introduction: Institute for Spine & Scoliosis, PA., understands that your medical information is private and confidential. Further we are required by law to maintain the privacy of “protected health information”. “Protected Health Information” includes any individually identifiable information that we obtain from you or others that relate to your past, present or future physical or mental health, and the health care you have received or payment for your health care. As required by law, this notice provides you with information about your rights and our legal duties and privacy practices with respect to the privacy of protected health information. This notice also discusses the uses and disclosures we will make of your protected health information. We must comply with the provisions of this notice as currently in effect although we reserve the right to change the terms of this notice from time to time and to make the revised notice effective for all protected health information we maintain.
Other Uses and Disclosures of Protected Health Information: In addition to using and
disclosing your information for treatment, payment and health care operations, we may
use your protected health information in the following ways:
Permitted Uses and Disclosures: We can use or disclose your protected health information for the purposes of treatment, payment and health care operations. For each of these categories of uses and disclosures we have provided a description below. However, not every particular use or disclosure in every category will be listed:
Treatment – means the provision, coordination or management of your health care including consultations between health care providers regarding your care and referrals for health care from one health care provider to another.
Health Care Operations – means the support functions of our practice related to treatment and payment such as quality assurance activities, case management, receiving and responding to patient comments and complaints, physician reviews, compliance programs, audits, business planning, development, management and administrative activities.
Payment – means the activities we undertake to obtain reimbursement for the health care provided to you, including billing, collections, claims management, determinations of eligibility and coverage and utilization review activities.
I, ______________________, acknowledge that I have been provided with a copy of Institute for Spine & Scoliosis, P.A.’s privacy notice.
Patient’s Signature Date