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Notice of Privacy Practices

Patients should review the document below for information on how the provider uses and discloses their personal, health, and financial information. These documents also outline the various privacy rights available to patients.

English (623 KB) (link opens in new window)

Spanish (656 KB) (link opens in new window)

Individual Rights Forms

The following is a brief description of the various individual rights and the appropriate form to invoke one of these rights.

Authorization for Release of PHI

This form requests an inspection or copy of protected health information about a patient. This form was last updated in June 2016.

English (53 KB) (link opens in new window)

Spanish (54 KB) (link opens in new window)

Accounting of Disclosures

This form requests a list of disclosures made of a patient’s protected health information. Disclosures made for payment and health plan operations are excluded from this process. The form was last updated in in June 2016.

English (59 KB) (link opens in new window)

Spanish (62 KB) (link opens in new window)

Amend

This form requests a correction to provider-created protected health information that a patient feels is inaccurate or incomplete. This form was last updated in June 2016.

English (59 KB) (link opens in new window)

Spanish (75 KB) (link opens in new window)

Complaint

This form documents an issue or concern if a patient believes his or her privacy rights may have been violated. This form was last updated in in June 2016.

English (57 KB) (link opens in new window)

Spanish (70 KB) (link opens in new window)

Confidential Handling

This form requests that the provider communicate with a member about protected health information in a different way during life-threatening situations. Examples of alternate means could include telephone, mail, e-mail, or different address. The form was last updated in in June 2016.

English (45 KB) (link opens in new window)

Spanish (103 KB) (link opens in new window)

Restriction & Termination of Restriction

This form requests or terminates limitations or restrictions of disclosures of a patient’s protected health information to others such as a family member, friend, spouse, doctor, or any other party. This form was last updated in in June 2016.

English (80 KB) (link opens in new window)

Spanish (52 KB) (link opens in new window)

Patient Consent for Representation

This form grants the provider permission to share your information to a trusted individual(s) that you choose. The form below allows you to choose the level of information to share with the trusted individual. You can specify any and all information, information specific to a treatment or injury, or something different. This form was last updated in in June 2016.

English (82 KB) (link opens in new window)

Spanish (93 KB) (link opens in new window)

Information regarding Advanced Directives

This document provides the patient with information regarding an advance directive regarding medical treatment when they are unable to make their wishes know because of illness or injury.

English (71 KB) (link opens in new window)

Spanish (75 KB) (link opens in new window)

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