Forms
Montgomery Medical Associates, PC

Forms

Notice of MMA Privacy Practices

Effective Date: June 18, 2001

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires us to ask each of our patients to acknowledge receipt of our Notice of Privacy Practices. You acknowledge receipt of this notice when you agree to receive medical services at Montgomery Medical.


Our Responsibilities

Under the Health Insurance Portability and Accountability Act of 1996, Montgomery Medical Associates is required to protect the privacy of your "Protected Health Information" (PHI). PHI includes information that we have created or received regarding your health or financial transactions associated with healthcare services provided to you. It includes both your medical records and personal information such as your name, social security number, date of birth, address, phone number, etc…


Uses and Disclosures of Your PHI

We disclose your PHI in connection with your treatment, receiving payments for your care, and in administration of our health care operations.

You have the right to:


Worker’s Compensation Form

For Work-Comp appointment please complete the Worker’s Compensation Form and fax it to the office.


Auto Accident Form

For Auto accident appointment please complete the Auto Accident Form and fax it to the office.


Emails

By utilizing emails, you acknowledge that you are aware that emails are usually not a secure method of communication, and that you agree to the risks involved. If you would prefer to exchange personal health information via a more secure method, please use our Online Patient Portal.