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The Department of Health and Human Services has established a “Privacy Rule” to help ensure that personal healthcare information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients’ consent for uses and disclosure of health information about the patient to carry out treatment, payment, and/or healthcare operations.
As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When appropriate, we provide the minimum necessary information to only those we feel are in the need of your health care information. This includes information about treatment, payment, and/or health care operations in order to provide health care that is in your best interest.
We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients) and may have to disclose personal health information for purposes of treatment, payment, or health care operations).
You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, if you refuse to disclose your Personal Health Information, we have the right to refuse to treat you. If you chose to give consent in this document at some future time you may request to refuse all or part of your PHI. You may not revoke actions that may have already been taken which relied on this or a previously signed consent.
If you have any objections to this form, please ask to speak to our HIPAA Compliance Office. You have the right to review our privacy notice, to request restrictions, and revoke consent in writing.

Signature: (For digital signature just enter your First, Middle, and Last Name below)


The misuse of PERSONAL HEALTH INFORMATION (PHI) has been identified as a national problem causing patients inconvenience, aggravation, and money. We want you to know that all of our employees, managers, and doctors continually undergo training to understand and comply with government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the “Privacy Rule.” We strive to achieve the very highest of standards of ethics and integrity in performing services for our patients. It is our policy to properly determine appropriate use of PHI in accordance with the governmental rules, laws, and regulations. We want to ensure that our practice never contributes in any way to the growing problem of improper disclosure of PHI. As a part of this plan, we have implanted a Compliance Program that we believe will help us prevent any inappropriate use of PHI.
We also know that we are not perfect! Because of this fact, our policy is to listen to our employees and our patients without any thought of penalization if they feel that an event in any way compromises our policy of integrity. More so, we welcome your input regarding any service problem, so that we may remedy the situation promptly.

I assign the right to payment for all medical benefits directly to Steven M. Block, D.P.M. in consideration for medical services and supplies provided to me pursuant to my health insurance plan.

In the event my health insurance plan refuses to pay for provided, medically reasonable and necessary services, I also assign all my ERISA* rights to Steven M. Block, D.P.M. for a full and fair review of any and all denied claims, including any penalties that may be assessed against the insurance company for claims processing violations. This ERISA assignment is in consideration for the unpaid services provided, in consideration for my insurance plan’s reduced fee schedule, and in consideration for the continued willingness of Steven M. Block, D.P.M. to see patients, including me, on an insurance assignment basis. I understand that if my treating doctor prevails in any payment dispute, I may be liable for any applicable co-payment for any contested services.

*ERISA is an acronym for the Employee Retirement Income Security Act. The Employee Retirement Income Security Act includes federal laws requiring insurance companies to process submitted insurance claims and appealed (denied) insurance claims according to ERISA regulations. The failure to process submitted insurance claims and appealed insurance claims according to ERISA regulations may result in fines charged to the insurance company in amounts up to $110 a day for each fraction.

Signature: (For digital signature just enter your First, Middle, and Last Name below)

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