Form 4

Patient Record of Disclosure

  • Facaros Foot and Ankle Patient Record of Disclosure In general, the HIPPA privacy rule gives individuals the right to request a restriction on uses and disclosure of their protected health information (PHI). The individual is provided the right to request confidential communication or with any communication of PHI be made by alternative means, such as sending correspondence to the individual’s office or home.
  • I wish to be contacted in the following manner (check all that applies)
  • It is the policy of this practice to protect the personal health information of every patient. The health and billing records we maintain are the physical property of the practice. The information in it however belongs to you. With your consent, the practice is permitted by the federal privacy laws to make uses and disclosure of your health information for purposes of treatment, payment, and healthcare operations.
  • YOUR RIGHS REGARDING YOUR PHI
  • • RIGHT TO RECEIVE A COPY OF NOTICE OF PRIVARY PRACTICES • RIGHT TO EXPECT THAT YOUR PHI REMAINS PRIVATE • RIGHT TO REQUEST RESTRICTION OF USAGE AND DISCLOSURE OF PHI • RIGHT TO REQUEST ACCESS TO YOUR PHIP • RIGHT TO REQUEST YOUR PHI BE AMMENDED

427 Egg Harbor Road

Sewell, NJ, 08080

(856) 589-0401

Call us today!

Opening Hours

Mon - Fri: 8:00 - 5:00

Appointment Booking

contact@facarosfootankle.com
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