E-Referral Form

E-Referral Form

**HIPAA Privacy Notice for Online Form Submissions**

This notice explains how your medical information may be used and disclosed and how you can get access to this information. Please review it carefully.

**Protected Health Information (PHI):** We may collect personal health information from you through online forms or other electronic means. This information is considered Protected Health Information (PHI) under the Health Insurance Portability and Accountability Act (HIPAA).

**Use and Disclosure of PHI:** Your PHI will only be used or disclosed as allowed or required by law. This may include:

– Treatment: We may use your PHI to provide you with medical treatment or services.
– Payment: We may use and disclose your PHI to obtain payment for the services we provide to you.
– Healthcare Operations: We may use and disclose your PHI for our healthcare operations, such as quality assessment and improvement activities.
– Authorization: We will obtain your written authorization before using or disclosing your PHI for purposes other than those described above, except as permitted or required by law.
**Your Rights:**
– You have the right to request restrictions on certain uses and disclosures of your PHI. We are not required to agree to these restrictions but will consider your request.
– You have the right to receive confidential communications of your PHI.
– You have the right to inspect and obtain copies of your PHI.
– You have the right to amend your PHI.
– You have the right to receive an accounting of certain disclosures of your PHI.
**Security Measures:** We take the security of your PHI seriously. We have implemented measures to protect the privacy and security of your information.
**Questions and Complaints:** If you have any questions or concerns about the privacy of your PHI or believe your privacy rights have been violated, please contact our Privacy Officer [Insert Contact Information].

**Changes to this Notice:** We reserve the right to change this notice and make the new notice apply to PHI we already have, as well as any PHI we receive in the future. The current notice will be posted on our website.

By submitting a form on our website, you acknowledge that you have read and understood this HIPAA Privacy Notice.