Orthopaedic Center of Okeechobee, P.A

ORTHOPAEDIC CENTER OF OKEECHOBEE, P.A.

BRADFORD A. SLUTSKY, M.D.

CONSENT AGREEMENT

Consent to the use and disclosure of Protected Health Information (PHI) for treatment, payment, and/or health care operations.

In accordance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, Orthopaedic Center of Okeechobee, P.A. may use and disclose protected health information(PHI) for its own treatment, payment, and/or health care operations. Generally, PHI is health information that is identifiable to a specific individual and that is maintained or transmitted by a medical office in oral, paper or electronic forms.

In order to provide you with quality care and to comply with certain legal requirements, we create a medical record of the care, treatments, and services you receive by our office. We are entitled to the use and disclosure of your PHI to carry out treatment, payment, and/or health care operations that is deemed necessary by the physician to ensure the highest quality of care is provided for the patient. We may verbally use and disclose PHI with close friends/family members that are directly involved in the care of the patient, unless the use and disclosure is restricted by patient. Otherwise, we will abide by the contents contained in our Notice of Privacy Practices(NPP) and as required by law.

INDIVIDUAL RIGHTS: (Patient)

By law, patients have rights that entitle them to the following:

• The right to review and obtain a copy of the Notice of Privacy Practices (NPP) used by this practice, that provides a more complete description of PHI uses and disclosures under HIPAA. Patients are entitled to the copy of NPP prior to signing this agreement.
• The right to receive confidential communications of PHI via telephone, writing, or electronically as permitted by law.
• The right to access, inspect, and/or obtain a copy of their PHI upon reasonable request and valid authorizations by patient.
• The right to object to the use of PHI for directory purposes.
• The right to request restrictions as to how their PHI may be used or disclosed to carry out treatment, payment, and/or health care operations; however, Orthopaedic Center of Okeechobee, P.A. is not required to agree to the restrictions requested. Please list any restrictions with use and disclosure of your PHI below:
• The right to revoke an authorization in writing, with the exception that any uses or disclosures previously made to the date of revocation will not be affected.

FACILITY DUTIES: (Orthopaedic Center of Okeechobee, P.A.)

The privacy of your medical information is important to us. We understand that your medical information is personal and confidential, and we are committed to protecting it. Orthopaedic Center of Okeechobee, P.A. is required by law to maintain the privacy of PHI and to provide individuals with our Notice of Privacy Practices (NPP) and legal duties with respect to PHI. We reserve the right to make changes and new provisions to terms of our NPP at any time, to be effective for all PHI that we maintain.

ACKNOWLEDGMENT: By signing below, I have fully read and understand the terms of this agreement. I further understand my individual rights and that I may obtain a copy of the Notice of Privacy Practices. I have been given the opportunity to request special restrictions as to the use and disclosure of my PHI.

Patient SignatureDate

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