Request for Medical Privacy

Request for Medical Privacy

I,_______________________________________ , date of birth,_____/_____/________; hereby inform and instruct Dr.______________________________, all associates, employees, staff and any affiliated company(-ies) of the following:

1)  My Social Security Number is not to be used as a medical or patient identification number.  I will not provide it and it is not to be recorded or kept anywhere by you in any form.

2)  If you use any form of electronic medical/demographic/billing records my information is to only be stored on your office computer/server system alone.  It is not to be stored/archived/backed-up on any system or server off-site.  No one other than you may access this information.

3)  You may release billing information only to my insurance company to include only basic demographic data (name, address, phone number, date-of-birth, non-SSN identification number), CPT and ICD-9 codes, dates of service and amounts billed.  You are not to release any medical information to my insurance carrier, including but not limited to vital signs, height/weight/BMI, or any particulars regarding test results, symptoms, physical findings, diagnoses or treatments beyond CPT/ICD-9 codes.

4)  You are not to release any information to any case management, disease management or wellness program or any similar such group.

5)  You are not to release any information, whether personally identifiable or not to any local, state or federal agency or any private or public for –profit or not-for-profit agency, business, university or organization for any reason.

This request remains in force until changed or revoked by me.

Thank you very much for respecting my privacy and my wishes.

Signed:________________________________________________________________

Name:_________________________________________________________________

Date:_____/_____/_________