HIPAA- The Health Insurance Portability & Accountability Act

This recently enacted law now affects all healthcare providers and their patients. The law is basically designed to protect the privacy and confidentiality of health information about you.  When you register at our office, you will be given a copy of this form to read and sign. This is our legal obligation, and it will inform you of our office practice procedures regarding disclosure of your confidential health information to others, what we may and may not do, and your legal rights.

      THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
      ABOUT YOU MAY BE USED AND DISCLOSED AND HOW
    YOU CAN GET ACCESS TO THIS INFORMATION

PLEASE READ IT CAREFULLY

    We are required by law to:

• make sure that medical information that identifies you is kept private.

• give you this notice of our legal duties 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 the medical treatment or services.  We may disclose medical information about you to doctors, nurses, technicians, medical students, insurance companies, attorneys, courts, or any other personnel who are involved in taking care of you as well as family members and  friends. If you choose NOT to have information released to a particular individual, company or other organization, please indicate the name(s) below along with your signature:
                   __________________________________________________________

                   __________________________________________________________

   Signature: __________________________    Date: ________________________

Right to request Confidential Communications:
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.  For example, you may ask that we only contact you at work or by mail.  This must be done in writing.

Appointment Reminders:
We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment , medical care, or that you should contact us to schedule an appointment.

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.  All amendment requests must be in writing and forwarded to our office at 3333 Fairmont Avenue, Asbury Park, N.J. 07712.  We may deny your request if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us 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
    Is accurate and complete

Our Notice of Privacy provides information about how we may use and disclose protected health information about you (as provided by, and required by law). You have the right to review or notice before signing it.  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 healthcare operations.  We are not required to agree to this rerstriction, 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 or healthcare 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                             Printed Name                                 Date