HIPAA Access Form

HIPAA NOTICE OF PRIVACY PRACTICESThe Clinic is required by federal and state law to maintain the privacy of your protected health information (PHI). PHI includes information about you, such as demographic details, that can identify you and relates to your past, present, or future physical or mental health condition and related services. By checking this box, you acknowledge receiving or being offered the Clinic's Notice of Privacy Practices.

HIPAA PROTECTED HEALTH INFORMATION ACCESSI understand that state and federal laws allow Family Circle of Care to share information about me, including my Protected Health Information (PHI), with family and friends involved in my care or the payment for my healthcare services. I also understand that I have the right to (i) grant specific individuals access to my PHI and (ii) restrict access to my PHI from specific individuals who would otherwise have access.

I would like for the following person(s) to have access to my Protected Health Information.

Name

Relationship to Patient

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name

Relationship to Patient

dob

name

Relationship to Patient

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name

Relationship to Patient

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ACCESS TO MEDICAL RECORDSI acknowledge that granting access does not provide the person with copies of my medical records. If I wish to request my medical records (e.g., immunization records, lab results, or physicals), I must complete an authorization form to release my protected health information.

AUTHORIZATION TO LEAVE CONFIDENTIAL INFORMATIONI consent to Family Circle of Care leaving confidential information, including appointment details, test results, and other healthcare-related information, on my voicemail or answering machine at the phone number(s) I have provided.

AUTOMATED COMMUNICATIONSI consent to receive automated communications via email, text, and phone (including autodialed and prerecorded messages) from the Clinic and its affiliates. These may include appointment reminders or billing information. I understand my carrier may charge fees for these messages. I may revoke this consent at any time by notifying the Patient Services Representative at the clinic's front desk.

COMMUNITY CONNECT AND OTHER MEDICAL DATABASESI understand that my provider participates in Christus’ Community Connect, and my patient data will be stored in a shared community electronic record. My clinical data may be shared with Christus, its affiliates, and other healthcare providers involved in my care. I authorize the Clinic to access and enter my protected health information in the statewide Med-IT® database.

AUTHORIZATION FOR RELEASE AND/OR ACQUISITION OF INFORMATIONI authorize the Clinic to release and obtain necessary protected health information from third parties, including other healthcare providers for ongoing care, and any insurance company or third-party payer to process claims or as permited by law. I release the Clinic from liability for the release or acquisition of this information. This authorization includes all blood tests and related screenings, including those for HIV and other diseases.

I acknowledge that I can modify this form at any time by contacting a Patient Services Representative at the clinic's front desk at Family Circle of Care. I understand that any changes or revocations will not apply to disclosures already made or access already granted based on this form.

By signing below. I agree to be bound by the provisions of this form.

Signature of Patient or Representative

Relationship to Patient

date

Cancel

HIPAA Protected Health Information Form

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