HIPAA PRIVACY AUTHORIZATION FORM
NINTH STREET INTERNAL MEDICINE ASSOCIATES, INC.
Authorization for use or disclosure of protected health information. (Required by the Health Insurance Portability and Accountability Act – 45 CFR Parts 160 and 164) Please list names and relationships of all persons that you authorize Ninth Street Internal Medicine Associates to release your medical information to during the course of your care:First Name Last Name Relationship Phone Number First Name Last Name Relationship Phone Number First Name Last Name Relationship Phone Number I hereby authorize all medical sources to release and disclose the following protected health information to:
NINTH STREET INTERNAL MEDICINE ASSOCIATES
805 Locust Street
Philadelphia, PA 19107
Phone: 215-440-8681
Specific Information to be disclosed: Entire Medical Record Only period of events from: Please describe Other: Please describe The information for which I’m authorizing disclosure will be used for the following purpose:Further Medical Care Other: Please describe
Important Information About Your Rights:
I understand that my records are protected under the Health Insurance Portability and Accountability Act, Federal Privacy Act, P.L. 93-575, the Federal Alcohol and Drug Abuse Act, P.L. 92-282, the Pennsylvania Mental Health Procedures Act, 1976 and the Pennsylvania Confidentiality of HIV Related Information Act, and therefore cannot be disclosed without my written consent unless otherwise provided for in the regulations. Under the Mental Health Act, this authorization expires one (1) month from the date of my signature. Under the Federal Alcohol and Drug Abuse Act, this authorization shall become void ninety (90) days from the date of my signature. In addition, I understand that I may revoke this authorization (except to the extent that action has been taken in reliance thereon) at any time by written, dated communication to the Ninth Street Internal Medicine and/or that my consent expires under the circumstance above. I understand that once copies of my information are provided, NSIM cannot prevent re-disclosure by the recipient. I understand that any information disclosed in response to this request will NOT include information related to my treatment for AIDS/HIV, psychiatric care/treatment, treatment for drug/alcohol, unless I specifically consent to release of this information by checking any or all the boxes below:AIDS/HIV Information Psychiatric Care/Treatment Treatment for Drug and Alcohol use/abuse
Patient Portal AccessOur practice offers a HIPAA secure patient portal for our patients that will allow you to send and receive non-urgent secure messages to our office regarding your health records, laboratory tests, and appointments, as well as give you access to view portions of your medical record online.
*We will respond to these email communications within 2 business days. Please note that urgent medical issues requiring same day attention continue to require that contact our office by phone. In addition, if you rarely check your email, please do not sign up for the patient portal.
CONSENT TO OBTAIN COMPLETE PRESCRIPTION MEDICATION HISTORYOur practice utilizes an integrated tool within our electronic medical records system that provides us with up-to-date information about all prescriptions given to you by all of your providers. It will allow us to view all medications dispensed to you, and help us to prevent adverse medication interactions. Please be assured that this is for the NSIM providers only and you may opt out of this feature at any time.By clicking below you certify that you have read and understand the scope of your consent and that you authorize access to your prescription medication historyI authorize NSIM to view my external prescription history *If you do not wish to take advantage of this service, please check below:I wish to opt out of this service