NOTICE OF PRIVACY PRACTICES
IMPAC Health is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.
Protecting the privacy of your personal health information is important to us. This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality assurance activities, public health, research, and law enforcement activities. Any other disclosures for the purposes of treatment, payment, or practice operations will be made only after obtaining your consent. You may request restrictions on disclosures.
Disclosures of protected health information are limited to the minimum necessary for the purpose of the disclosure. This provision does not apply to the transfer of medical records for treatment.
You may inspect and receive copies of your records within 30 days of receiving a request to do so. There may be a reasonable cost-based fee for photocopying, postage and preparation.
You may request changes of your records. Our practice has the right to accept or deny your request.
We maintain a history of protected health information disclosures that is accessible to you.
In the future, we may contact you for appointment reminders, announcements, and promotional events and to inform you about our practice and its staff.
Our practice is required to abide by this notice. We have the right to change the notice in the future. Any revisions will be prominently displayed in a clearly visible location in our office.
You may file a complaint about privacy violations by contacting Dr. Delene Bivolcic.
I have read the Privacy Notice and understand my rights contained in the notice.
By way of my signature, I provide IMPAC Health with my authorization and consent to use and disclose my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice.
Patient’s Name (print)
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Patient’s Signature
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