Patient Acknowledgment of the Notice Of Privacy Practices and Consent Form
The Department of Health and Human Services has established a "Privacy Rule" to help insure that personal healthcare information is protected. The privacy rule was created in order to provide a standard for certain health care providers to obtain their patient's consent for uses and sharing with others health information regarding treatment, payment, and healthcare options.
As our patient we want you to know that we respect the privacy of your personal medical records and will do all that we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide only the minimum necessary information to those we feel are in need of your information in order to provide care that is in your best interest.
We also want you to know that we support your full access to your personal medical records. We may have indirect relationships with other (for example a laboratory) and may have to disclose personal health information for the purpose of treatment, payment, or healthcare operations. These partners in your healthcare are also most often not required to obtain patient consent.
You may refuse to consent to the use or disclosure of your personal information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI).
If you choose to give consent in this document, at some future time you may request to refuse to release all or part of your PHI. You may not revoke your decisions that have already been taken which relied on this or a previously signed consent.
Our NOTICE OF PRIVACY PRACTICES describes in detail how medical information about you may be used or shared and how you can get access to the information. There is a current copy of this notice available in the lobby of each Pioneer Physicians Network, Inc. medical office and a full and complete copy will be offered to you at no charge. You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.
If you have any questions or objections to this form, please ask to speak with the Office Manager or our HIPPA Privacy Officer.
__________________ ________________ Date __/__/___ Signature Print Name
Connect With US
Office Hours Monday, Tuesday & Friday: 9:00 am - 5:00 pm Wednesday & Thursday: 9:00 am - 6:00 pm
Contact Info 137 East Ave., Suite 100, Tallmadge, OH 44278 Phone: 330-630-2580