HIPAA Privacy & Confidentiality

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. This form is a userfriendly version to explain your rights and our responsibilities with your Protected Health Information (PHI). There are rules and restrictions regarding who may see or be notified of your PHI. Additional information is available from the U.S. Department of Health and Human Services at www.hhs.gov. Our goal at Kemet is to use these regulations in ways to provide you with the best quality of professional service and care. Toward this end, we have adopted the following policies:

1. Patient information will only be shared among treatment team members and administrative staff as necessary to provide services. Records will be used in provider and administrative offices while treatment is being planned and carried out, but staff will have exclusive access. Records are locked in areas when staff members are not in the clinic.
2. Your information will be shared with other healthcare providers, laboratories, and health insurance payers only as is necessary and appropriate to your care, such as for medical emergencies or for qualified audits/evaluations, and comply with state and federal regulations.
3. Kemet may require a number of vendors to help us operate our clinic. They may have access to PHI in the course of their work but must agree to abide by our policies and HIPAA regulations.
4. Kemet agrees to provide patients access to their records in accordance with HIPAA regulations and state law.
5. You may request restrictions on the use of your information and your request will be followed to the degree that federal and state regulations and safety and quality of care allow. Some disclosures are allowed by way of a court order. Crimes against staff or on Kemet premises are not protected, including instances of child abuse or neglect.
6. Your PHI will not be used for the purpose of marketing of products, goods, or services.
7. You agree to bring any concerns about the use of your PHI to the attention of your treatment team.

Obtaining Prior Medical Records (optional): *

If you wish to release medical records, where from?

Placing Expiration on Consent (optional):

I understand that my alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations. I understand that violations of these laws are a crime and will be reported to the appropriate authorities as such situations arise. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows:

Acknowledgements

I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes. I have been provided a copy of this form (by downloading this file, or alternatively, in the patient packet if you receive one).In signing below I certify that I fully understand and agree to the information on this form.Should I have any questions, now or during treatment, I will ask my treatment team or refer to www.hhs.gov.

Patient first name *

Patient last name *

Email *

Date of birth *

Please let parent, guardian, or your personal representative sign below:

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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HIPAA Privacy & Confidentiality

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