Under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, as amended, patients have the right to agree, restrict, or object to providing Protected Health Information (PHI) to family members, friends, and/or other persons identified as involved in the patient’s care or payment for the patient’s health care. To comply with the regulations, as outlined in Triad HIPAA Privacy Policy 007, documentation of the patient’s wishes must be present in the medical record.
Unless you object, PHI can be disclosed to those individuals listed below. Additionally, you authorize our staff to update this list per your direction.
I, , hereby allow Northeast Internal Medicine to disclose my PHI information (condition, treatment, prognosis, and billing) to the following individual(s):
