IMAD OBEID MD
SAM HAMADE MD
KEVIN POTTS MD
FRANCO PARODI MD
AMARAJA KANITKAR MD
SHANNA PEARSON DO
DONOVAN OGBOH DO
The Privacy Rule generally requires health care providers to take reasonable steps to limit
the use or disclosure of, and request for PHI to the
minimum necessary to accomplish the intended purpose. The provisions do not apply to uses or
disclosures made pursuant to an authorization
requested by the individual. Health care entities must keep records of PHI disclosures.
Information provided below, if completed properly will
constitute an adequate record. NOTE: USES AND DISCLOSURES MAY BE PERMITTED WITH OUT PRIOR
CONSENT IN AN EMERGENCY!
PATIENT RECORD OF DISCLOSURES
In general, the HIPPA Privacy Rule gives individuals the right to request a restriction on
uses and disclosures of their Protected Health
Information (PHI). The individual is also provided the right to request confidential
communications or that a communication of the PHI is made
by alternative means such as sending correspondence to the individuals office instead of
their home.
I wish to be contacted in the following manner (check all that apply)
PERSONAL CONTACTS OR FAMILY THAT YOUR PHYSICIAN /STAFF ARE ALLOWED TO SPEAK TO
I HAVE RECEIVED THE NOTICE OF PRIVACY PRACTICES AND PATIENT PROVIDER AGREEMENT
(PCMH)
