Privacy Policy

SISTERHOOD SANCTUARY LLC

HIPAA INFORMATION & PRIVACY POLICY CONSENT FORM

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA

requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version.

A more complete text is posted in the office. What this is all about: Specifically, there are rules and restrictions on who may see or be

notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary

to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with

our goal of providing you with quality professional service and care. Additional information is available from the US Department of

Health and Human Services at www.hhs.gov. We have adopted the following policies:

1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative

matters related to your care are handled appropriately. This specifically includes the sharing of information with other health

care providers, laboratories, and health insurance payers as is necessary and appropriate for your care. Patient files may be

stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is already a

matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in

administrative areas, such as the front office, examination room, etc. Those records will not be available to persons other than

office staff. You agree to the normal procedures utilized within the office or for the handling of charts, patient records, PHI and

other documents or information.

2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, email, US mail or by any

means convenient for the practice and/or as requested by you. We may send you other communications informing you of

changes to office policy and new technology that you might find valuable or informative.

3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI, but must agree

to abide by the confidentiality rules of HIPAA.

4. You understand and agree to inspections of the office and review of documents which may include PHI by government

agencies or insurance payers in normal performance of their duties.

5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.

6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.

7. We agree to provide patients with access to their records in accordance with state and federal laws.

8. We may change, add, delete or modify any of these provisions to better serve the needs of both the practice and the patient.

9. You have the right to request restrictions in the use of your protected health information and to request change in certain

policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your

request.

I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent

changes in office policy. I understand that this consent shall remain in force from this time forward.

__________ I agree

Signature:__________________________________________________________________________________

Date:______________________________________________________________________________________

▢ Please check box if you consent to receive text messages/emails of lab results

By providing a telephone number, you consent to be contacted by text message from Sisterhood Sanctuary LLC at the phone

number/email provided. Message frequency varies. Message and data rates may apply. Carriers are not liable for any delays or

undelivered messages. Reply STOP to opt-out. View our Privacy Policy.

With whom may we discuss or disclose information about your care, treatment, diagnoses, or lab results? (Please list name,

relationship and phone number) please list them here:

_____________________________________________________________________________________________

PATIENT PRIVACY POLICY

No personal information will be shared with third parties/affiliates for marketing/promotional purposes.

PATIENT RECORDS DISCLOSURE

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health

information (PHI). The individual is also provided the right to request confidential communications, or that a communication of PHI be

made by alternative means, such as sending correspondence to the individual’s office instead of to the individual’s home.

I wish to be contacted in the following manner (check all that apply):

__________ home phone number

__________cell phone number (Call and Texting). By providing a telephone number, you consent to be contacted by text message

from Sisterhood Sanctuary LLC at the phone number provided. Message frequency varies. Message and data rates may apply.

Carriers are not liable for any delays or undelivered messages. Reply STOP to opt-out. View our Privacy Policy.

__________leave a phone message with DETAILED INFORMATION

__________leave a phone message with a CALL-BACK NUMBER ONLY

__________mail to my home address (as listed in my chart)

__________mail to my work / office (as listed in my chart)

__________fax

__________email

Please enter preferred contact information:___________________________________________________________

Your printed name:______________________________________________________________________________

Your signature:_________________________________________________________________________________

Date: ________________________________________________________________________________________