Under HIPAA, we may discuss your protected health information, including care or financial information with individuals involved in your care if you are not present or do not have the capacity to agree or object, if in the professional judgment of PREventClinic physician or other caregivers, we conclude that the disclosure is in your best interest. The disclosure is limited, in this circumstance, to protected health information that is directly relevant to that individual’s involvement in your care.
If you would like to identify specific individuals to whom we may make the foregoing disclosures, such as in the event PREventClinic is unable to reach you or in response to an inquiry, please list them when you check in.
Communications: We always seek to communicate with you efficiently and securely. The modes of communications that have been shown to meet these objectives include the use of the patient portal (myChart), mobile (SMS/MMS) messaging and telephone/voicemail messaging. We may send appointment reminders, test results, prescription refills and billing communications through these modes:
I understand the contact information on this form will be used to communicate with me regarding my medical and financial information until such time as I notify PREventClinic in writing of a change.
HIPAA Acknowledgement: I acknowledge I have been provided with Notice of Privacy Practices.
Electronic Medical Records and Prescription Access: I acknowledge that the office uses electronic medical records and may use such system to look at and prescribe medications.
Signature of Patient/Guardian Date