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I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPPA) I have certain rights to privacy regarding my protected health information. My health information will be used to: 1) Conduct, plan, and direct my treatment and follow-ip visits among the multiple healthcare providers who may be directly or indirectly involved in my treatment. 2) Obtain payment from third party payers (insurance providers, plans, or other) 3) Conduct normal healthcare operations such as quality assessment and physicians certifications. I have read the above information, and understand this Notice of Privacy Practices pertaining to the uses and disclosures of my health information. I understand that the practice of Dr. Sinclair has the right to update its Notice of Privacy Practices from time to time, and that I have the right to obtain a current copy of such practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand that your are not required to agree to y requested restrictions, but if you do agree, you are bound to abide by such restrictions:
If Dr. Sinclair’s office has agreed to accept insurance for services rendered, it is understood that this does not completely relieve me of all financial obligations. I have read and understand this information, and by signing below, I acknowledge that understanding:
I authorize Dr. Sinclair to disclose complete information concerning his medical findings and treatment of me, from the initial office visit until the date of conclusion of such treatment, to parties who Dr. Sinclair determines to be required to receive such information for the purpose of medical treatment, medical quality assurance, and peer review:
I hereby give permission to Alexander Sinclair to take necessary photographs and images related to my medical services. These photos will be used for medical records, healthcare, insurance coverage, and data for informational/instruction purposes. The term, “photograph”, as used in this agreement, shall mean any image or motion picture with or without audio in any format. This term also includes digital files, printed or electronic radiology exam results, or any other mechanical means of reproducing images. Your insurance provider may request copies of the photographs in order to evaluate your claim, and by signing below, you agree to release your images for that purpose. The undersigned has entered into this agreement in order to assist scientific treatment, education, and public relations. The undersigned waives any rights to compensation for these uses by the reason of the foregone authorizations, and the undersigned/successors or assigned guardians hereby hold the surgical center, its employees, Dr. Sinclair, and any other person participating in my care harmless against any claim for injury or compensation resulting from the activities authorized by this agreement. Neither the undersigned, nor any family members, or assigned guardians will be identified by name. The undersigned agrees to release Dr. Sinclair from all rights I my have over the images.
