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HIPAA Privacy Notice & Acknowledgment

Required signature at first visit

Notice of Privacy Practices

Effective Date: January 1, 2024

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

Our Pledge Regarding Medical Information
Roth Family Medicine & Mental Health understands that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements.

How We May Use and Disclose Medical Information About You
We may use and disclose your protected health information (PHI) for the following purposes without your authorization:

Treatment: We may use your PHI to provide, coordinate, or manage your health care and related services.
Payment: We may use and disclose your PHI to obtain payment for services we provide to you, including billing your insurance company.
Health Care Operations: We may use and disclose your PHI to support the business activities of our practice, including quality assessment, employee review, and training.
As Required by Law: We will disclose your PHI when required to do so by federal, state, or local law.
Public Health Activities: We may disclose your PHI for public health activities such as reporting communicable diseases.
Abuse or Neglect: We may disclose your PHI to a government authority if we reasonably believe you are a victim of abuse, neglect, or domestic violence.

Your Rights Regarding Medical Information About You
You have the following rights regarding medical information we maintain about you:

Right to inspect and copy your medical records
Right to request amendments to your records
Right to an accounting of disclosures
Right to request restrictions on use and disclosure
Right to request confidential communications
Right to a paper copy of this notice

Changes to This Notice
We reserve the right to change this notice and to make the revised notice effective for medical information we already have about you as well as any information we receive in the future.

Complaints
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact us at (208) 904-4705 or [email protected]. You will not be penalized for filing a complaint.

Contact Information
Roth Family Medicine & Mental Health
444 Hospital Way, Suite 422
Pocatello, ID 83201
Phone: (208) 904-4705

Patient Information

First Name*

Last Name*

Date of Birth*

Authorized Representatives (Optional)

If you would like us to share your health information with a family member, caregiver, or other person, please list them below.

Authorized Person Name

Relationship

Phone

Authorized Person Name

Relationship

Phone

Acknowledgment

I acknowledge that I have received and reviewed the Notice of Privacy Practices for Roth Family Medicine & Mental Health. I understand how my health information may be used and disclosed, and I understand my rights regarding my health information. *

Patient / Guardian Signature (type full name)*

Date*

Relationship to patient (if signing on behalf of patient)