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Referral Form

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Protecting the Privacy of Patients’ Health Information

YOUR INFORMATION REQUIRED TO BE PROTECTED.

The privacy of all medical records and other individually identifiable health information must be protected at all times. Information relating to a patient’s health care history, diagnosis, condition, treatment, or evaluation shall be considered individually identifiable health information. Confidentiality of this health information must be maintained at all times, and may only be disclosed with the express written consent of the patient.

Non-individually identifiable health information, (e.g. health information that cannot be linked to a specific patient) is not included within the definition of protected health information

Insurance Accepted