HIPAA  PRIVACY OF MEDICAL INFORMATION FORM
PLEASE READ CAREFULLY

We are required by law to:

• Make sure that medical information which can identify you is kept private

• Give you this notice of our legal obligations and privacy practices with respect to medical information about you, and

• Follow the terms of the notice that is currently in effect

For Treatment and Payment:
We may use medical information about you to provide you with medical treatment or services.  We may disclose medical information about you to other physicians, nurses, technicians, medical students, insurance companies, lawyers, courts, family members, friends,  or any other personnel who are involved in taking care of you.  If you choose NOT to have such information released to  particular individuals, please indicate their names below, and sign it beneath:

___________________________________________________________________________________

______________________                          _______________________
  (Your signature)                                                     (Date of signing)

Right to request confidential communications:
You have the right to request the we communicate with you about medical matters in a certain way or at a certain location.  For example, you can ask that we only contact you at work or by mail....  or that we do not contact you at work.  This request must be in writing.

Appointment reminders:
We may use and disclose medical information to contact you as a reminder that you have an appointment for an examination or treatment for medical care.

Right to inspect and copy:
You have the right to inspect and copy medical information that may be used to make decisions about your care.

Right to Amend:
If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend that information. This request must be in writing and forwarded to our office at 3333 Fairmont Avenue, Asbury Park, N.J. 07712.  We may deny the request if it is not in writing or does not include a reason to support the request.  In addition, we may deny your request to amend information that was not created by us, is not part of the medical information kept by, or for, our office, is not part of the information which you would be permitted to inspect and copy, or information which is accurate and complete.

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you.  You have the right to review our notice before signing.  If we change our notice, you may obtain a revised copy.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations.  We are not required to agree to this restriction, but if we do, we are bound by our agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations.  You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.

________________________        _______________________       __________________
       ( Patient Signature)                            (Please Print Name)                             (Date)