All patients of the Health Services are required to fill out a
Consent Form, informing them of their right to privacy:
Department of Health and Human Services has established a "Privacy
Rule" to help ensure that personal information is protected for
privacy. The Privacy Rule was also created in order to provide
a standard for certain health care providers to obtain their
patients' consent for uses and disclosures of health information
about the patient to carry out treatment, payment or health care
As our patient, we want you to know that we respect the privacy
of your personal medical information and will do all 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 the minimum necessary
information to only those we feel are in need of your health care
information (including information about treatment, payment or
health care operations) in order to provide health 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 treatment
relationships with you (such as laboratories that only interact with
physicians and not patients), and may have to disclose Personal
Health Information (PHI) for purposes of treatment, payment, or
health care operations. These entities are most often not
required to obtain patient consent.
You may refuse to consent to the use or disclosure of your PHI,
but this must be in writing. Under this law, we have the right
to refuse to treat you should you choose to refuse or disclose your
PHI. If you choose to give your consent in this document, at
some future time you may request to refuse all or part of your PHI.
You may not revoke actions that have already been taken which relied
on this or previously signed consent.
If you have any objections to this form, please ask to speak with
our HIPAA Compliance Officer. You have the right to review our
privacy notice, to request restrictions an revoke consent in writing
after you have reviewed our privacy notice."