Podiatry Associates of New Mexico, LTD

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL/PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.

Summary:

By law, we are required to provide you with our Notice of Privacy Practices (NPP). This Notice describes how your medical information may be used and disclosed by us. It also tells you how you

can obtain access to this information.

As a patient, you have the following rights:

1. The right to inspect and copy your information;

2. The right to request corrections to your information;

3. The right to request that your information be restricted;

4. The right to request confidential communications;

5. The right to a report of disclosures of your information; and

6. The right to a paper copy of this Notice.

We want to assure you that your medical/protected health information is secure with us. This Notice contains information about how we will insure that your information remains private.

If you have any questions or concerns about this Notice, please contact our Privacy Officer, Terri Schultz at
505-797-1001 ext. 111.

Acknowledgement of Notice of Privacy Practices

“I hereby acknowledge that I have received a copy of this practice’s NOTICE OF PRIVACY PRACTICES. I understand that if I have questions or complaints regarding my privacy rights that I may contact the person listed above. I understand that the practice will offer me updates to this NOTICE OF PRIVACY PRACTICES should it be amended, or changed in any way.”

* I authorize my physician and his/her staff to contact me by the designated means noted below:

(Please check all that apply)

___ Home Phone ___ Home Answering Machine/Voice Mail ___Office/Work Place, Voice Mail

___ Cell Phone/Voice Mail

* I authorize my physician and his/her staff to communicate information regarding appointments, medical results and billing issues to: (Please print each name in this area)

___ Spouse ___________________________

___ Others: ___________________________, __________________________, _____________________________

________________________________________ ________________________________________________

Patient or Representative Name (please print) Patient or Representative Signature Date

Patient refused to sign Patient was unable to sign because ________________________________