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.
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…
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:
Request restriction(s) to limit the way we disclose your PHI for treatments, payments, or health care operations. Please fax or email the Request for Restriction(s) Form to our office.
Request for alternate means of communication with you such as a different address, email or fax.
Request a copy of your PHI. Please fax or email Authorization for Disclosure of Medical Records to our office. Please note that there may be a charge for this service.
Request to correct or amend your PHI in our files. Please fax or email the Amendment of Health Record Request Form to our office.
Request an accounting of release of your PHI to third parties. Please fax or email the Request for Accounting of Disclosures and provide us with the specific information that we need in order to respond.
Request a release of information to Family Members / Power of Attorney. Please fax or email the Authorization for Release of Health Information to our office.
For Work-Comp appointment please complete the Worker’s Compensation Form and fax it to the office.
For Auto accident appointment please complete the Auto Accident Form and fax it to the office.
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.