Rittenhouse Women's Wellness Center

Available Forms

A.) Internal Medicine Authorization to Release Healthcare Information A.) Internal Medicine Health History Form A.) Internal Medicine HIPAA : Notice of Privacy Practices A.) Patient Registration B.) Dermacenter Client Information and History C.) Nutrition 3 Day Food Diary C.) Nutrition History D.) Dr. Perilstein: Emotional Well-being Authorization to Release Protected Health Information D.) Dr. Perilstein: Emotional Wellbeing Consent for Treatment D.) Dr. Perilstein: Emotional Wellbeing Receipt of Privacy Information E.) Dr. Liggera's Patient Registration Form F.) Payment and Cancellation Policy G.) Email Agreement

A.) Internal Medicine HIPAA : Notice of Privacy Practices

HIPAA: Notice of Privacy Practices

By checking this box, I understand the following: 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. You will be asked to acknowledge that you have received our notice of privacy practices. We understand that information about you and your health is very personal and therefore, we will strive to protect your privacy as required by law. We will only use and disclose your personal health information as allowed by applicable law. We are required by law to maintain the privacy of our patients' personal health information and to provide you with notice of our legal duties and privacy practices with respect to your personal health information. We are required to abide by the terms of this Notice of Privacy Practices so long as it remains in effect. We reserve the right to change the terms of this Notice of Privacy Practices as necessary and to make the new Notice of Privacy Practices effective for all personal health information maintained by us. USES AND DISCLOSURES OF YOUR PERSONAL HEALTH INFORMATION The following categories detail the various ways in which we may use or disclose your personal health information. For each category of uses or disclosures we will give you illustrative examples. It should be noted that while not every use or disclosure will be listed, each of the ways we are permitted to use or disclose information will fall into one of the following categories. Your Authorization. Except as outlined below, we will not use or disclose your personal health information for any purpose unless you have signed a form authorizing the use or disclosure. This form will describe what information will be disclosed, to whom, for what purpose, and when. You have the right to revoke that authorization in writing, except to the extent we have already relied upon it. Uses and Disclosures for Treatment. We will make uses and disclosures of your personal health information as necessary for your treatment. For instance, doctors, nurses, and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to plan a course of treatment for you that may include procedures, dications, tests, etc. Uses and Disclosures for Payment. We will make uses and disclosures of your personal health information as necessary for payment purposes. For instance, we may forward information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you or we may use your information to prepare a bill to send to you or to the person responsible for your payment. Persons Involved In Your Care. Unless you object, we may in our professional judgment disclose to a member of your family, a close friend, or any other person you identify, your personal health information to facilitate that person's involvement in caring for you or in payment for that care. We may use or disclose personal health information to assist in notifying a family member, personal representative or any other person that is responsible for your care of your location and general condition. Finally, we may also disclose limited personal health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you. Appointments and Services. We may use your personal health information to remind you about appointments or to follow up on your visit. Business Associates. Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, legal services, etc. At times it may be necessary for us to provide certain of your personal health information to one or more of these outside persons or organizations who assist us with our payment/billing activities and health care operations. In such cases, we require these business associates to appropriately safeguard the privacy of your information. Other Uses and Disclosures. We are permitted or required by law to make certain other uses and disclosures of your personal health information without your consent or authorization. Subject to conditions specified by law: We may release your personal health information for any purpose required by law; We may release your personal health information for public health activities, such as required reporting of disease, injury, and birth and death, and for required public health investigations; We may release your personal health information to certain governmental agencies if we suspect child abuse or neglect; we may also release your personal health information to certain governmental agencies if we believe you to be a victim of abuse, neglect, or domestic violence; We may release your personal health information to entities regulated by the Food and Drug Administration if necessary to report adverse events, product defects, or to participate in product recalls; We may release your personal health information to your employer when we have provided health care to you at the request of your employer for purposes related to occupational health and safety; in most cases you will receive notice that information is disclosed to your employer; We may release your personal health information if required by law to a government oversight agency conducting audits, investigations, inspections and related oversight functions; We may use or disclose your personal health information in emergency circumstances, such as to prevent a serious and imminent threat to a person or the public; We may release your personal health information if required to do so by a court or administrative order, subpoena or discovery request; in most cases you will have notice of such release; We may release your personal health information to law enforcement officials to identify or locate suspects, fugitives or witnesses, or victims of crime, or for other allowable law enforcement purposes; We may release your personal health information to coroners, medical examiners, and/or funeral directors; We may release your personal health information if you are a member of the military for activities set out by certain military command authorities as required by armed forces services; we may also release your personal health information if necessary for national security, intelligence, or protective services activities; and We may release your personal health information if necessary for purposes related to your workers' compensation benefits. Confidentiality of Alcohol and Drug Abuse Patient Records, HIV-Related Information, and Mental Health Records. The confidentiality of alcohol and drug abuse patient records, HIV-related information, and mental health records maintained by us is specifically protected by state and/or Federal law and regulations. Generally, we may not disclose such information unless you consent in writing, the disclosure is allowed by a court order, or in limited and regulated other circumstances. RIGHTS THAT YOU HAVE Access to Your Personal Health Information. Generally, you have the right to access, inspect, and/or copy personal health information that we maintain about you. We will charge you for a copy of your medical records in accordance with a schedule of fees established by applicable state law. Amendments to Your Personal Health Information. You have the right to request that personal health information that we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. All amendment requests, in order to be considered by us, must be in writing, signed by you or your representative, and must state the reasons for the amendment/correction request. If an amendment or correction you request is made by us, we may also notify others who work with us and have copies of the uncorrected record if we believe that such notification is necessary. Please note that even if we accept your request, we may not delete any information already documented in your medical record. Restrictions on Use and Disclosure of Your Personal Health Information. You have the right to request restrictions on certain of our uses and disclosures of your personal health information for treatment, payment, or health care operations. For example, you may request that we do not share your health information with a certain family member Confidential Communications. You have the right to request communications regarding your personal health information from us by alternative means or at alternative locations and we will accommodate reasonable requests by you. You must request such confidential communication in writing to each department to which you would like the request to apply. Paper Copy of Notice. As a patient you retain the right to obtain a paper copy of this Notice of Privacy Practices, even if you have requested such copy by e-mail or other electronic means. You may also print this web page or download a copy (requires free Adobe Acrobat Reader). ADDITIONAL INFORMATION Complaints. If you believe your privacy rights have been violated, you may file a complaint in writing with the doctor's office. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington D.C. All complaints must be made in writing and in no way will affect the quality of care you receive from us. Effective May 1, 2008. *

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