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HIPAA Acknowledgement and Consent to Treat

HIPAA Acknowledgement and Consent to Treat

01.22.2014 | About your care, Patient Forms

Notice of Privacy Practices

Download the HIPAA Acknowledgement and Consent to Treat Form

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. To view the entire Notice of Privacy Practices you may download the Privacy document via the link above.
Effective September 23, 2013

Our Pledge Regarding Medical Information
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at the Provider. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated or maintained by the Provider, whether made by Provider personnel or your personal doctor.

This Notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:
• Make sure that medical information that identifies you is kept private;
• Give you this Notice of our legal duties and privacy practices with respect to medical information about you; and
• Follow the terms of the Notice that is currently in effect.

 

Who Will Follow This Pledge?
This Notice describes Urological Associates of Southern Arizona, P.C. (hereafter referred to as ‘Provider’) Privacy Practices and that of:

Any workforce member authorized to create medical information referred to as Protected Health Information (PHI) which may be used for purposes such as Treatment, Payment and Healthcare Operations. These workforce members may include:
• All departments and units of the Provider.
• Any member of a volunteer group.
• All employees, staff and other Provider personnel.
• Any entity providing services under the Provider’s direction and control will follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for Treatment, Payment or Healthcare Operational purposes described in this Notice.

 

Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe we have violated your privacy rights. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

UASA reserves the right to change its policies and procedures as needed and will make this notice available upon request to individuals whenever a material change is implemented.

You may contact, in writing, our Administrator for further information about the complaint process at:

Urological Associates of Southern Arizona Attention:
Administrator
6325 East Tanque Verde Road
Tucson, AZ 85715