HIPAA Guidelines

Please read this form which explains your privacy rights. Our policy establishes requirements for staff, patients and physicians regarding access to your private health information (PHI). Our office was designed from the ground up to be compliant with HIPAA regulations which were established in 2001 and multiple revisions have occurred since implementation in 2003 and 2005. Those authorized with access to your information are responsible for properly storing and restricting access to your information. Many providers will ask you to sign a waiver allowing us to disclose your information without risk of HIPAA penalties. We are attempting to follow all of the privacy rights you need without asking you to sign a waiver.  You do have to fill out this form though.  Misuse of your private health information will be regarded with the utmost seriousness. Any alleged violation should be reported to our security officer as soon as possible and an investigation will be made available to you or to a security auditor regarding any access of your health records. In our facility we use an electronic medical record. We scan in any paper documents AND YOUR DRIVERS LICENSE you might bring in and we backup that information and store it in another facility in case of emergency. We have methods to operate in emergency mode where your information is not available but also have mechanisms in place to migrate your archived information back to your medical record. In our office your studies will be performed without patient identifying information except for a internal coded identifier. This unique identifier is stored in your electronic medical record. Any access to your electronic medical record to locate this identifier can be audited and tracked. When you arrive at our office you will be given a card with your special identifier which can be used on future visits. Your PHI can be utilized for treatment, and this information can be shared with your insurance company and other health care providers for your treatment to progress. We do submit your health information to your insurance provider by electronic data exchange. By using the unique identifier in our office in most cases even if people physically break in to our offices they cannot identify which study belongs to which patient unless they also have passwords and access to our servers. We have a security audit each year to see if we are in compliance with HIPAA regulations. While you can elect to have no communication from our office. We will only accept you as a patient if we are able to call you in case we need to contact you. You may provide an alternate number or change your contact information at any time. This contact information is also protected in your electronic medical record.

If you feel your patient confidentiality has been compromised, you can contact our HIPAA custodian.  Currently this is Dr. Philip W. Chao.  He will try to help you determine who has accessed your records and should be able to tell you when and if any access to your information occured.

Check one: Allow phone calls Do not call Do not contact

Please note that the following data interchanges,
may occur with your electronic imaging data.
Check here to allow us to send your images to your referring doctor? If yes, Will you allow us always to send your images to other requesting physicians?
Please check if you want us to do the following:
Email you (encrypted) when your images are accessed
when your report is ready If you want us to fax you a report when it is ready
You agree to allow us to disclose this information via encrypted email or secure fax You want us to use your cellphone to notify you
You allow us to contact you - when you have any questions You will allow us to give you telephone reminders prior to your examination
You give us permission to request your medical records from prior exams which can specify below Do you wish to specify a healthcare proxy

All patients, please complete the following:
Is this form clear and concise?: Yes No
Do you understand this form?: Yes No

Please list any exams which you wish us to compare or look at reports
(e.g. CT,MRI,PET,Nuclear Medicine,xray ) Yes No
If yes, please describe:

Before entering the MR environment you MUST remove all metallic objects including hearing aids,dentures,partial plates,keys,beepers,cellphones,eyeglasses,hair pins,safety pins,paperclips,money clip, credit cards, magnetic strip cards, coins,pens,pocket knife,scissors,nail clipper,tools,clothing with metal fasteners or zippers and clothing with metallic threads. Do you have any other questions?
Please. make sure you ask the technologist Yes No
If yes, please describe:

Referring doctor:

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