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HIPAA AUTHORIZATION FOR USE OR
DISCLOSURE OF HEALTHCARE INFORMATION
Department of Health and Human Services has established a “Privacy Rule” to help ensure
that personal health care information is protected for privacy. The privacy rule was also
created in order to provide the standard for certain healthcare providers to obtain their
patient’s consent for uses in disclosures of health information about the patient to carry out
treatment, payment or healthcare operations.
As our patient, we want you to know that we respect the privacy of your personal medical
records and we will do all we can to secure and protect that privacy. We strive to always
take reasonable precautions to protect your privacy. When appropriate and necessary, we
provide the necessary information to only those whom we feel are in need of minimum
healthcare information about treatment, payment or healthcare operations in order to
provide healthcare that is in your best interest.
We also want you to know that we support your full access to your medical records. We
may have indirect treatment relationships with you (such as laboratories that only interact
with physicians not patients) and may have to disclose personal health information for
purposes of treatment, payment or healthcare operation. These entities are most often not
required to obtain patient consent.
You may also refuse to consent to the use of disclosure of your personal healthcare
information, but this must be in writing. Under this law, we have the right to refuse to treat
you should you choose to refuse to disclose your personal health information (PHI). If you
choose to give consent in this document at some future time, you may request or refuse all
or part of your PHI. You may not revoke actions that have already been taken which relied
on this or a previously signed consent.
If you have any objections to this form, please ask to speak with our office staff or our
HIPAA compliance officer.
You have the right to review our policy notice, to request restrictions and to revoke
consents in writing after you have reviewed our policy notice.
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Gregory A Stainer MD
