Forms

Notice of Privacy Practices

Your health care provider and health plan must give you a notice that tells you how they may use and share your health information. It must also include your health privacy rights. In most cases, you should receive the notice on your first visit to a provider or in the mail from your health plan. You can also ask for a copy at any time or review using the link below.

Components of the Notice of Privacy Practices:

• Must state how the Privacy Rule allows provider to use and disclose protected health information. It must also explain that your permission (authorization) is necessary before your health records are shared for any other reason. 
• The organization's duties to protect health information privacy. 
• Your privacy rights, including the right to complain to HHS and to the organization if you believe your privacy rights have been violated. 
• How to contact the organization for more information or to make a complaint. 

Click here for the Notice of Privacy Practices 

Patient Release of Information Form 

This form must be used to authorize disclosure of protected health information. 

Click here for ROI form