At Pediatric SuricalCare, we place the highest priority on a patient’s right to privacy. We are committed to providing you and your family with exceptional care and forming a relationship that is build on trust. This means that we respect your right to privacy and will endeavor to protect the confidentiality of you and your family health information–whether this information is stored in a paper or electronic file.
I understand that the information in my record may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or infection with the Human Immunodeficiency Virus (HIV). It may also include information about behavioral or mental health services or treatment for alcohol and drug abuse.
Right to Revoke:
I understand that I have the right to revoke the authorization at any time. I understand if I revoke this authorization I must do so in writing. I understand that the revocation will not apply to information that has already been released based on this authorization.
Unless otherwise revoked, this authorization will expire on the following date, event, or condition: If I do not specify an expiration date, event or condition, this authorization will expire in six months.
I understand that any disclosure of information carries with it the potential for redisclosure and the information may not be protected by the federal confidentiality rules.
I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I do not need to sign this form to assure treatment. However, if this authorization is needed for participation in a research study, I may be denied enrollment in the research study. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.524.
If I have any questions about disclosure of my health information, I can contact the System Manager in the Health Information Management Department at 201-225-9700