Ohio Holistic Healthcare

570 North Leavitt Road

Amherst, OH 44001

(440) 340-1970 (phone)

(440) 370-3026 (fax)



HIPAA Information and Consent Form  

*Complete and bring to your appointment

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy.  Implementation of HIPAA requirements officially began on april 14, 2003.  Many of the policies have been our practice for years.  This form is a “friendly” version.  A more complete text is posted in the office for your reference.

What HIPAA is all about:  Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI).  these restrictions do not include the normal interchange of information necessary to provide you with office services.  HIPAA provides certain rights and protections to you as the patient.  We balance these needs with our goal of providing you with quality professional services and care.  Additional information is available from the U.S. Department of Health and Human Services at www.hhs.gov.

We have adopted the following policies:

  1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately.  This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care.  The normal course of providing care may incorporate that patient records are possibly left, at least temporarily, in administrative areas, such as the front office, examination room, etc.  those records will not be available to persons other than office staff.  You agree to the normal procedures utilized within the office for the handling of charts, patient records,PHI, and other documents or information.
  2. It is the policy of this office to remind patients of their appointments.  We may do this by telephone, text, e-mail, U.S. mail, or by any means convenient for the practice and/or as requested by you.  We may from time to time send you other announcements or communications informing you of changes to office policy and new technology that you might find valuable and/or informative.
  3. Our practice utilizes a number of vendors in the routine conduct of daily business.  These vendors may have access to PHI, but must agree to abide by the confidentiality rules of HIPAA.
  4. Our practice also participates in various medical university and advanced health practitioner educational training programs.  Any participating students may have access to PHI, but must agree to abide by the confidentiality rules of HIPAA.
  5. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
  6. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the physician.
  7. Your confidential information will not be used for the purposes of marketing or advertising of products, goods, or services.
  8. We agree to provide patients with access to their records in accordance with state and federal laws.
  9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI.  however, we are not obligated to alter internal policies to conform to your request.

I,_________________________________________________________on this date ___________________________________ do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM above and any subsequent changes in office policy:  I understand that this consent shall remain in force from this time forward.