Cedar Creek Family Medicine

11492 Old US Hwy 52, Winston-Salem, NC 27107

Ted Nifong, MD -- Lexi Nifong, MD -- Julie Bain, PA-C

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HIPAA Information Consent Form

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect our privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have existed in our practice for years. This form is a friendly version; a more complete text is posted in the front office of Cedar Creek Family Medicine at 11492 Old US Hwy 52, Winston-Salem, NC 27107.

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 those needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services (www.hhs.gov).

We have adopted the following policies:

1. Patient information will be kept confidential 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, 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 not already a matter of public record.

2. 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 confidentiality rules of HIPAA.

3. You understand and agree to inspections of the office and review of documents which may include PHI by regulatory entities, but these entities must agree to abide by the confidentiality rules of HIPAA.

4. You agree to bring any concerns or complaints regarding privacy to the attention of the practice owner(s).

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

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

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

8. You have the right to request restrictions in the use of your protected health information (PHI) and to request change in certain polices used with the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

   
   

Please list the following people we are allowed to give information regarding your care:

Please check the following that apply:

Acknowledgement Form

If patient is under the age of 18, the Responsible Party will click "I AGREE" below. Otherwise, patient will click "I AGREE" below.

I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION CONSENT FORM and any subsequent changes in office policy. I understand that this consent shall remain from this time forward, with no expiration date.