Notice of Privacy Practices
It has always been the policy of this office to protect the privacy of our patients. The first time you visit our office, you will be asked to sign the Patient Information Consent form, which concerns your personal health information and how we provide information to you, other health care providers, and to your insurance company.
The Federal Government established privacy guidelines under the Health Insurance Portability and Accountability Act (HIPAA). These guidelines establish the patient's right over the use and disclosure of his or her own personal health information and to protect patients' personal health information from unauthorized breaches of privacy.
In accordance with the HIPAA guidelines, we are required to obtain patient consent for use or disclosure of patient health information. Consent is required only once. New consent is required only if the patient revokes consent between treatments. Revoking consent must be done in writing. You may not revoke actions that have already been taken which relied on this previously signed consent.
In signing the document you understand and provide consent for the use and disclosure of your personal health information to carry out treatment, payment and operations of health care services. It is our policy to bill your insurance company should you wish us to do so. When billing your insurance company, it is necessary we notify them of the reason(s) for your visit. Operations of health care may include any information that might be shared with outside providers such as laboratories, pathologists and other physicians.
Jay S.H. Masserman, M.D., Inc.,
11180 Warner Ave. Ste. 455
Fountain Valley, CA 92708-7505